What to inject first, the filler or PRP?

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.

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.

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,