What to inject first, the filler or PRP?

Question

I want to inject fillers in my face , also I want to try PRP ( although there is a great controversy in its effectiveness), what should I inject first? Also, what should be the centrifuge machine? I heard that the reason some people are not getting good results with prp is that the machine that centrifuge the blood and prepare the prp is not good to give the right concentration of growth factors? Your advice please

James R. Gordon, MD, FACS, FAAO · Answer

Thank you for sharing your question. It probably does not matter too much, but I would suggest have PRP with Microneedling performed first. It is important to make sure your doctor is an expert in both treatments in order to avoid serious complications.  Good luck,

Jason Emer, MD · Answer

Typically I do PRP / Sculptra in a combination deeply in the temples, jawline, deep cheeks/folds and on top we layer other fillers.  Combine with lasers and thermage for best outcomes.  Dr. Emer.

John G. Alevizos, DO · Answer

I inject fillers first to frame the face, then PRP in the same areas for a better and longer lasting effect. If you are young or are on optimal natural bio identical hormones, instead of filler alone lasting six months together with PRP (Vampire facelift), will last a minimum of two years. The growth factors work better when we have youthful hormone levels. If you are over 40 a simple blood test, covered by your insurance, will give us the information we need. I don't place fillers under the eyes as they can clump, instead I use activated PRP for smooth appearance.

Michele S. Green, MD · Answer

I typically like to inject Voluma for cheeks and Juvederm Ultra plus for smile lines, to give the best cosmetic results. I have patients return in 2 weeks to assess their injections and " touch-up" any needed areas.

Best,

Dr. Green

Best,

Dr. Green

Andre Berger, MD · Answer

These treatments can be combined for the best results. When performed at the same time, you will not only save on office visits but will see the most dramatic differences in appearance.

As always, consult a trusted professional for tailored feedback.

In good health,

Dr. Berger

Steven F. Weiner, MD · Answer

The filler is the only thing that will give you noticeable results in my opinion. Therefore, do this first. PRP needs to be at a concentration of 6X the normal platelet concentration to be optimal. Most offices sell PRP that is about 2X and this is not very effective. It has to with the PRP system they are using. To get more effective PRP, the offices have to spend significantly more on machines and this is a purchase they can't afford or desire to spend for.

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed many facial shaping procedures for over 30 years using dermal fillers, silastic facial implants (cheeks, chin and lips) and have performed many SMAS facelifts and minimally invasive SMAS facelifts.  Using precise placement of a dermal filler is highly effective at creating the proper aesthetic shape to the cheeks, chin, lips and jaw line.   Similarly, a proper SMAS facelift is designed to tighten the underlying SMAS (through the proper imbrication technique), remove excess skin from the face and neck which reduces "jowls" in the lower face.  The same can not be said about the gimmick type PRP lifts or Fat injection lifts given all sorts of exotic names like "vampire lift" or "stem cell" lifts.  These are marketing "hyped" injections of unreliable (not scientifically proven to provide the touted benefits) tissue products and not true facelift procedures.  The excuse that the blood was not properly spun down does not ring true.  There are "no" living cells in PRP.  Plasma serves a purpose in blood but has no "magical" SMAS or skin lifting or tightening capabilities when injected into the face.  The same can be said about injecting fat...no matter how it's treated, spun or mixed with blood factors.  This is the main reason to consult with and seek treatment from an experienced Facelift Surgeon.  If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
 My most popular SMAS facelift is the minimally invasive, short incision SMAS facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesia
proper SMAS Imbrication technique
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
 I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.  The reality is, there are many different ways to perform a facelift from incision length, incision placement, level of tissue dissection (skin only, SMAS, Deep Plane, Subperiosteal), different degrees of tissue undermining, how to lift and support (imbrication versus plication of the SMAS layer), how much excess skin to trim, is excess fat going to be reduced and finally will the overall shape of the face be made more feminine or masculine (while avoiding the over pulled, windswept appearance).  Price is determined by the reputation, location and experience of the Facelift Surgeon.
 In my humble opinion however, there are some basic requirements that must be met in order for a facelift to be "effective", yielding "aesthetic pleasing" and "naturally attractive" results.  These include: 
 1. Some type of incision either curved around the front (preferred) or straight in front of the ear.  This is how excess skin is removed which is not possible with an incision behind the ear alone.  If you have so little excess skin on the face that "none" needs to be removed you are not a candidate for a facelift in the first place.
2. The facelift must address correction and softening of the "jowls" using a long lasting and effective technique.  If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
3. Facial shaping must be combined to properly shape the cheeks, chin, jaw line and lips for feminizing or masculinizing the face as the case may be.  Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  If the cheeks are flat or concave in the front, cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.  Conversely, men look chiseled and handsome when angularity is created in the cheeks, chin and mandibular angles.  
 When the chin is weak, this creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.  I have found placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.  I have performed many facial shaping procedures using dermal fillers, facial implants (cheek, chin), liposuction and/or facelifts for over 30 years.  In my experience and despite its recent increase in popularity, fat transfer (fat injection) offers "far" less of a reliable and predictable volume for facial shaping than an off the shelf dermal filler or silastic facial implant.  For that reason, I do not use fat to shape the cheeks, chin, lips or jaw line.  Tissue physiology is quite simple.  Tissue requires a blood supply in and out as well as lymphatic connections to remain viable and alive.  Once fat is removed from the body all of these things have been disrupted.  Just because the removed fat is mixed with PRP or something else doesn't make the blood and lymphatics magically re-appear.  The fat at that point is not living tissue which means that it's prone to being dissolved by the body (most likely in an uneven and unpredictable manner).  Injecting fat back into the face does not create the required elements to make the fat living tissue once again.  So the argument that fat is alive and viable in the face once it's been removed and re-injected makes no sense to me as a physician and surgeon.
 The other issue that I have with fat transfer is the lack of precision.  Fat is thick by nature which means it's not the same consistency as an off the shelf dermal filler.  Fat injections use an increased volume injected in an attempt to compensate for the volume loss that "will" happen.  This means a lack of specific shape and volume that simply can not begin to compare with the specificity of using a silastic facial implant of a "known" shape and volume.  In that regard fat offers too much of an unknown to make it a reliable and predictable method for facial shaping.  There's a significant difference between a 3mm and 5mm thick cheek implant.  You can imagine the magnitude of difference there is between retaining 60% of 25cc's of fat versus 35%.  In my humble opinion, I just don’t see how fat could possibly be used to precisely shape facial features? Finally, these injections are not benign.  PRP and fat can and do create tissue inflammation, lumpiness and internal scarring that can make the face appear "odd" and subsequent facelift procedures more difficult to perform.
Hope this helps.

Amiya Prasad, MD - Account Suspended · Answer

Thank you for your question. You’re asking between fillers or PRP, which to inject first, the possible controversies associated with PRP, and which centrifuge to use. I think you’re looking for some guidance as to what roles PRP and fillers have in facial enhancement.
I can certainly give you some guidance as to how I educate my patients. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping people look their best through non-surgical facial rejuvenation is something we do every day, and we use a lot of PRP in our practice.
We’ll begin by understanding some basic principles of what fillers and PRP do, and where there may be some opportunity for synergy. PRP is platelet-rich plasma which is derived from your own blood. It is a concentration of the wound healing factors that help improve collagen, blood supply, and a variety of other things that also improve fat cells under the skin. It’s been well established in medical literature to have value in a variety of situations, including being well established in oral and orthopedic surgery. In aesthetics, PRP has become more recognized, and has been proven through very good scientific data from a microscopical level.
I think one of the challenges is many doctors are not educated and choose not to pursue any knowledge about PRP, so are quick to dismiss it. This is not unusual when it comes to the medical world of people who don’t know something about an area will often dismiss it because they think if it was significant, they would know it.  The reality is medical education is often dictated by the messaging of very well-funded, large scale pharmaceutical companies, and device companies. With platelet-rich plasma (PRP), there is no multimillion company - it’s a very basic, simple technology that uses your own blood. The knowledge is gained through education the doctor has to pursue and experience, so it’s understandable why there is confusion in terms of validity.
In terms of equipment, it’s comparable to the way the laser companies try to prove to the practitioner or the consumer that one laser is better than the other. Again, it’s about the knowledge of the doctor and the way the doctor applies the technology for the benefit of the patient. Often, doctors like to advertise or promote and distinguish themselves from the others by saying they have a piece of equipment that other people don’t. Since most doctors who practice aesthetics can essentially afford any piece of equipment they need, a centrifuge is on the cheaper end s for people who own lasers worth hundreds of thousands of dollars. It’s not a big stretch to go buy a centrifuge, so from an equipment point of view, you should take that with a grain of salt. 
From my personal knowledge and experience of the evolution of PRP for aesthetics, for years it was frequently in South American countries like Columbia before it was used in the United States. I can tell you from looking at the clinical experience of colleagues from these countries, in South America the equipment was very basic and straightforward. In the early articles about PRP from oral surgery literature where dental implants were able to heal better within the mouth when PRP was used, this was in the late 90s where the centrifuges were even less complicated.
If you understand the principle, and you have a doctor who has experience with PRP, there’s no reason to get hung up on a particular single piece of equipment. I’ve used a lot of different kits, different centrifuges, and I have my own personal biases on how I use and prepare PRP, which are the things that work for me and are effective for my patients. 
PRP is not a substitute for fillers. PRP can stimulate collagen, stimulate the fat cells, and improve vascularity. There can be somewhat of a volumizing effect, but it varies and it cannot be a substitute when you want more robust volume correction, which is where fillers play a role. We use fillers at multiple levels in the face starting at the deepest, which we call structural volumizing. This is where we use a long lasting filler like Juvederm Ultra Plus, Juvederm Voluma at the deeper levels under the muscles, and on top of the bone to give you more cheek structure and definition, jawline structure, and chin projection.
When asking what to do first, fillers or PRP, it depends on what you need. I would suspect you are dealing with volume loss issues, so fillers are your foundation. You can think of it that way - fillers for foundation, or something to restore volume if needed. PRP is a way to restore skin health, quality, and glow. In many ways, it’s counteracting the natural deterioration of the skin, and the soft tissue below the skin. With stimulation, the body generates increased volume and fat, collagen, and vascularity. With PRP you’re getting something for the superficial levels, and with the fillers, you’re getting something at the deeper levels. 
Where does the synergy opportunity come in? One example is when I treat acne scars, where I routinely combined hyaluronic acid filler with PRP to restore volume, and synergize in a way to get a more permanent correction with this combination. This has already been established in one particular study I’m thinking of where the combination of PRP and hyaluronic acid actually improve wound healing in exposed bone . There’s another opportunity, for example, in the under eye hollow area where the tear trough, I’ll place a filler like Restylane, then PRP at just under the skin level, so synergy - you’re getting volume, healthier skin, and a more global, youthful appearance.
I think you need to find a doctor you feel really understands your needs before you commit to a particular pursuit of one type of solution. A physician’s role is to guide you in identifying what the issues are most significant for you, and the optimal strategies, which usually many choices. I routinely ask the patient what their main concern is, which is usually to look younger, more healthy, and then they focus in on a few things that bother them like lines, jowls, or marionette lines - things like that. What I’ll do is take their picture, put them up on the screen, and then we’ll decide together what makes sense with them, then we work on a process that fits their timeframe and their budget.  I hope that was helpful, I wish you the best of luck, and thank you for your question.

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