Content uploaded by Erdenetsogt Dungubat
Author content
All content in this area was uploaded by Erdenetsogt Dungubat on Aug 12, 2017
Content may be subject to copyright.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
1
Research
Morphometric study of facial wrinkles and aesthetic skin as
dermaroller treatment combined with platelet rich plasma (PRP)
S. Oyunsaikhan1, B. Amarsaikhan2, B. Batbayar1, D. Erdenetsogt3
Affiliation:
1- Department of Oral and Maxillofacial Surgery, School of Dentistry, Mongolian National University of
Medical Sciences;
2- Department of Prosthodontics, School of Dentistry, Mongolian National University of Medical
Sciences;
3- Department of Pathology, School of Biomedicine, Mongolian National University of Medical Sciences.
Abstract
Background: Facial wrinkles are a multifactorial, complex process that negatively affects
individuals’ appearance, consequently their quality of life. The treatment for these wrinkles
varies with the degree of severity. This prospective study aimed to evaluate the clinical effect of
pure dermaroller and dermaroller combined with platelet rich plasma therapy (PRP
dermaroller), to treat facial wrinkles, and to quantitatively evaluate histological changes of the
skin that occur in the two different cohorts.
Methods and materials: Twenty healthy women aged 43-48 years with scores ranging between
2 and 4 on the baseline facial fine wrinkle grading scale were enrolled in the this clinical study.
Nineteen of the patients were treated with a pure dermaroller on the one half of face, and with
a dermaroller that included a platelet rich plasma on the other half of the face. Three
treatments, each in a 4 weeks interval were performed. Standard photographs and skin biopsies
were obtained from the treatment area at baseline and 8 weeks after the final session.
Comparisons of the treatments were analyzed using clinical and histological findings.
Results: The degree of baseline facial fine wrinkle grading scale after treatment revealed
statistically significant effects of the PRP dermaroller treatment side compared to the side of
pure dermaroller treatment. At 8 weeks after the final session, the wrinkling grade on the PRP
dermaroller side and the pure dermaroller side showed significant differences (p<0.05).
Microscopic evaluation of haematoxylin eosin and Masson’s trichrome stained sections revealed
significant differences in dermal fibers, epidermal thickness, papillae and skin glands.
Conclusion: Significant changes were noted between treatments of facial wrinkles with pure
dermaroller and PRP dermaroller. Dermaroller combined with platelet rich plasma is a promising
novel method of facial rejuvenation.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
2
Keywords: dermaroller, platlet rich plasma, wrinkle, skin aging.
Background
Facial wrinkles are a multifactorial, complex process that negatively affects individuals’
appearance, consequently their quality of life [1]. Aged skin displays with reduced number of
dermal glands, fibroblasts, dermal fibers, and diminished ability of recovery. These findings are
consistent with an atrophy of the dermal extracellular matrix (ECM) [2,3]. The treatment for
these wrinkles varies with the degree of severity. Several therapeutic options are available
today: muscle-relaxing injections, topical medications, dermabrasion, chemical peels, laser
resurfacing, cosmetic filler injections and collagen induction therapy. Microneedling with
dermarollers is a cheap and simple procedure for facial skin wrinkle. It is a technique that uses
a sterile dermaroller to puncture the skin multiple times with a series of fine sharp needles. The
skin develops multiple microbruises in the dermis that initiate the complex cascade of wound
healing and growth factor release, and finally results in collagen production [4,5]. Platelet rich
plasma (PRP) is an autologous preparation of platelets in concentrated plasma that may be
beneficial in the treatment of wrinkles by promoting collagen deposition [6]. Platelet rich plasma
contains multiple autologous growth factors, including epidermal growth factor, fibroblast
growth factor, transforming growth factor-b, macrophage inflammatory protein-1α, platelet
derived growth factor and vascular endothelial growth factor [6,7,8]. The combination of skin
needling and topical PRP could enhance the efficacy of both modalities. In cosmetics, PRP has
been used for facelift, neck lift, breast augmentation, breast reduction, autologous fat transfer,
and lip augmentation [9]. This prospective study aimed to evaluate the clinical effect of a therapy
applied to facial wrinkles by treatment with pure dermaroller and of a PRP dermaroller. The
morphological changes in the skin were quantitatively evaluated between the two methods of
treatment.
Methods
Patients
From October 2015 to February 2016, a total of twenty healthy women with facial wrinkles with
scores ranging from 2 to 4 on the baseline facial fine wrinkle grading scale [8] <Table1> were
enrolled in the this clinical study. All patients were informed and agreed to a written consent.
The local ethics committee approved the protocol in accordance with the principles of Good
Clinical Practice and the Declaration of Helsinki.
The average patients’ age was computed to 45.47±1.92 years (range, 43 to 48 years). Our study’s
exclusion criteria included: facial skin rejuvenation done in the previous 1 year; age below 43 or
above 48; severe skin allergies; use of any drugs which affect platelet function; herpes labialis;
bacterial infection; actinic keratosis; skin cancer; systemic retinoids intake in the previous 6
months; diabetes; hematologic disorders; severe mental illness; pregnancy or lactation. A single-
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
3
blinded prospective trial was implemented for avoiding bias. The sides of the patients’ face were
randomly selected for treatment with pure dermaroller and PRP dermaroller.
Treatment protocols
Three treatment sessions each at 4 weeks interval were carried out of microneedling on the one
half of the face, and contemporary skin needling combined with platelet rich plasma on the
other half of the face.
Control group
Three treatment sessions each at 4 weeks interval were carried out of the pure dermaroller on
one half of the face and contemporary of the PRP dermaroller on the other half of the face. Local
anesthetic cream (lidocaine) was applied to the face for approximately one hour before the
procedure. After sterilization of the face with povidone iodine, 1.5-2 ml of PRP was applied
topically to the treated area, followed by needling on the one half of face using the sterile
dermaroller (Shanghai Astiland Technology Co., Ltd, Shanghai, China). It consists of 540 stainless
steel needles; needle length is 1.5 mm long in a cylindrical assembly. The treatment was
performed by rolling the dermaroller on the one half of face 10 times in 4 directions (vertically,
horizontally, and diagonally right and left) with soft pressure.
Experimental group
Skin needling combined with platelet-rich plasma was carried out on the other half of the face.
Platelet-rich plasma was obtained by double-spin method, followed by the collection of 10 ml
of autologous whole-blood into tubes containing anticoagulant, finally produce 1.5～2.0 ml of
PRP. The collected blood was first centrifuged at 215 g for 10 minutes to separate the red blood
cells at the bottom of the tube, the buffy coat (containing the white blood cells) in the middle
and the plasma above. The upper plasma was pipetted from the buffy coat and underwent an
additional centrifugation at 863 g for 10 minutes in order to obtain a platelet pellet in the bottom
of the tube, and a platelet-poor plasma (PPP) in the upper part. The PPP is partly removed and
partly used to re-suspend the platelets to finally produce 1.5-2.0 ml of PRP. Platelet-rich plasma
was activated by adding 10% calcium chloride 0.1 ml per 0.9 ml plasma. 1.5-2 ml of PRP was
applied topically to the treated area, followed by needling the skin.
Histological analysis
Histology was performed using a 3 mm punch biopsies from the skin (treatment site) at baseline
and 8 weeks after the final session. Specimens were fixed in 10% buffered formalin, embedded
in paraffin, sliced into sections 5 μm thick and stained with Haematoxyline Eosin (HE) and
Masson’s Trichrome (MT). The HE stained skin specimens were reviewed for epidermal
thickness, papillae, pigmented epithelial cells and glands. The MT stained skin specimens were
measured for dermal fibers. Measurements of the epidermal thickness and dermal fibers were
carried out with Diskus® Software and a light microscope (Olympus BX51, Japan). 2 to 3
randomly selected zones per histological slide of each individual patient were measured
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
4
rectangular from the basal layer to the top of the stratum corneum. All microphotographs
shared the same power of 10X objective. Data of the cutaneous casts were analyzed by
computerized image analysis.
Outcome assessments
Standard photographs and skin biopsies were obtained from the treatment area at baseline, at
8 weeks after the final treatment. Photographic documentation was performed using identical
camera settings and lighting and the same positioning with the same camera (Canon 6D, Canon
Corp., Tokyo, Japan). Grading of wrinkle photographs using the baseline facial fine wrinkle
grading scale <Table1> [10] was carried out by three dermatologists who did not participate in
the treatment and were not informed of the treatment modalities on each side.
Grade
Grade 0
No evidence of line or wrinkle.
Grade 1
A few short barely perceptible wrinkles.
Grade 2
A few shallow wrinkles discreetly visible with no deep wrinkles in the face.
Grade 3
Shallow easily visible wrinkles with 1 or 2 shorter deeper wrinkles in the face.
Grade 4
Moderate number of fine wrinkles nearly covering the entire area, with wrinkles
deeper and longer in the face.
Grade 5
Many deep lines with several coarse wrinkles.
Table1: Baseline Facial Fine Wrinkle Grading Scale.
Statistical Analysis
Data were checked, entered, and analyzed using RStudio (Version 1.0.44) and SPSS (Version
19.0). Data were represented as mean ± SD for quantitative variables. Numbers and percentages
were used for categorical variables. Before-and-after treatment comparisons were performed
using the parametric t-test for paired samples. The statistical tests were two-sided, and a
probability value of less than 5% was considered statistically significant. The differences in the
degree of improvement and percentage improvement between groups were compared using an
independent sample t-test. Statistical analysis was performed using the chi-square test.
Significance was accepted at a level of p˂0.05.
Results
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
5
Demographics
Twenty patients were enrolled in the study, nineteen patients completed the three sessions
treatment. One patient withdrew due to pain during dermaroller treatment. The mean age was
45.47±1.92 years with a range of 43 to 48 years <Table 2>.
Clinical variables
Total cases
19
Age, years
Mean ± SD
45.47±1.92
Range
43 – 48
Gender
Male
0 (0%)
Female
19 (100%)
At baseline wrinkle grade
Experimental group
Control group
Grade 0
0 (0%)
0 (0%)
Grade 1
0 (0%)
0 (0%)
Grade 2
1 (5.3%)
2 (10.5%)
Grade 3
12(63.2%)
11 (57.9%)
Grade 4
6 (31.6%)
6 (31.6%)
Grade 5
0 (0%)
0 (0%)
P value
P=0.331>0.05
Table 2: Demographics of the 19 patients who completed the study.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
6
Figure 1: Clinical improvement of facial wrinkles on both sides. a baseline, b at 8 weeks after the final
session on the dermaroller combined with PRP treatment, c baseline, d at 8 weeks after the final session
on the dermaroller treatment.
Clinical improvement
The degree of facial wrinkling was compared between the experimental group or the control
group at before treatment and at 8 weeks after the final session <Figure 1>. At baseline, the
wrinkling grade on the dermaroller combined with PRP side (3.26 ± 0.56) and the pure
dermaroller side (3.21 ± 0.63) showed no significant differences (p>0.05). At 8 weeks after the
final session, the wrinkling grade on the dermaroller combined with PRP side (2.32 ± 0.82) and
the pure dermaroller side (2.89 ± 0.66) showed high significant differences (p<0.05).
Experimental group
Control group
Group
Baseline
after treatment
Baseline
after treatment
N
19
19
19
19
Average
3.26±0.56
2.32±0.82
3.21±0.63
2.89±0.66
p value
P=0.000<0.01
P=0.011<0.05
p value
(after treatment)
P=0.001<0.01
Table 3: Clinical improvement of facial wrinkles on both groups.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
7
Histological results
The microscopic evaluation of the HE stained sections revealed significant difference in
epidermal thickness, papillae, pigmented epithelial cells and skin glands. An increase in
epidermal thickness between the experimental and the control group was noted <Figure 2>.
The epidermal thickness measured 163.44±5.99 μm at baseline, 235.8±31.94 μm at 8 weeks
after the final session on the PRP dermaroller (P<0.05); 200.61±14.09 μm at 8 weeks after the
final session on the pure dermaroller (P<0.05) <Table 4>.
Figure 2: Microphotographs taken of representative skin samples stained with hematoxylin-eosin
presenting the epidermal thickness. a baseline, b at 8 weeks after the final session of the dermaroller
combined with PRP treatment, c at 8 weeks after the final session of the dermaroller treatment. The
increase in thickness of the epidermis with repetitive treatments in addition to the PRP dermaroller and
the dermaroller demonstrates how effective these combined techniques are. Furthermore, it can be seen,
that the stratum corneum is more compact in the experimental (b) and control (c).
Group
Dermaroller combined with PRP
Pure Dermaroller
Baseline
After
Change(%)
Baseline
After
Change(%)
Epidermal
thickness
(μm)*
163.44±5.99
235.8±31.94
44.23٭
163.44±5.99
200.61±14.09
22,74٭
Number of
epidermal
papillae *
0.37±0.49
2.84±1.21
667.57٭
0.37±0.49
1.42±0.96
283,78٭
Number of
dermal
glands*
0.58±0.51
5.00±1.37
762.06٭
0.58±0.51
3.84±2.06
562.07٭
Density of
dermal
fiber(mm2)*
0.348±0.003
0.502±0.025
44.25٭
0.348±0.003
0.409±0.016
17.53٭
Table 4: The main histological findings of the two groups. Quantity of Epidermal thickness, dermal glands
and epidermal papillary count, and number, and dermal fiber.٭Statistically significant difference (p < .05)
comparing before and after treatment. *Statistically significant difference between combination
treatment with platelet-rich plasma (PRP) and pure dermaroller treatment.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
8
A significant increase in the number of dermal glands and epidermal papillary <Table 4> between
the experimental and control group could be noted. The glands and epidermal papillae in the
experimental group were increased compared to the control group (P<0.05) <Table 4>.
MT stained slides displayed with a considerable increase in dermal fiber deposition at 8 weeks
after the final session. Their microscopic evaluation <Figure 3> revealed a significant difference
in dermal fibers of the PRP dermaroller cohorts (baseline and at 8 weeks after the final session;
<0.05), and between the PRP dermaroller and pure dermaroller cohort at 8 weeks after the final
session (P <0.05) <Table 4>.
Figure 3: Microphotographs taken of representative skin samples stained with Masson’s trichrome
presenting the dermal fiber. a baseline, b at 8 weeks after the final session of the dermaroller combined
with PRP treatment, c at 8 weeks after the final session of the dermaroller treatment.
Graph 1: Quantitative analysis of the elastic fibers. It demonstrates significant different distributions of
dermal fibers between the areas of PRP dermaroller and pure dermaroller treatment.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
9
Discussion
We observed remarkable differences of clinical and histological findings between the two
cohorts in this study. The PRP dermaroller group displayed with an objective improvement of
facial wrinkle grade, an increase in the epidermal thickness, epidermal papillae, dermal glands
and dermal fiber density.
The clinical changes associated with aging of the skin include pigment alterations, thinning,
dryness, fine wrinkling, and coarser textural changes such as sagging and wrinkling [2, 11].
Microscopically, aged skin possesses a decreased dermal thickness and vascular density, a
reduced number of dermal fibroblasts, glands and levels of collagen and elastin [12]. The
regeneration of human skin in terms of cellular replacement and wound healing decreases with
age [13]. In the present study, the treatment with PRP dermaroller increased the epidermal
thickness, the number of epidermal papillae and dermal gland, as well as the thickness of
collagen fibers. As a result, we believe that PRP dermaroller treatment might pose a positive
effect to reverse skin damages, for example, in patients with poor wound healing capacity due
to aging.
In a study from Korea, twenty-two participants (age range: 30–56) underwent three sessions of
fractional laser; 11 were treated with topical application of PRP combined with fractional laser.
One month after the final treatment, PRP combined with fractional laser increased the subjects’
satisfaction and skin elasticity, and decreased the erythema index. PRP increased the thickness
of the dermo-epidermal junction, the amount of collagen, and the number of fibroblasts [13].
In a study from Germany, 480 patients with fine wrinkles, lax skin, scarring, and stretch marks
were treated with percutaneous collagen induction using the dermaroller (length 3mm)
combined with topical vitamin A and C cosmetic creams to produce tighter, smoother skin. Most
patients underwent only one treatment, some patients underwent until to four treatments. On
average, the patients in Germany rated their improvement 60 % to 80 % after their treatment.
The epidermis demonstrated 40% thickening of the stratum spinosum and normal rete ridges
after 1 year [4].
The microscopic skin examination of our 19 patients revealed a considerable increase in collagen
and elastin deposition after 6 months. In this study, the increase of epidermal thickness was
measured to 44.23% in the PRP dermaroller cohort.
Ryan et al. have shown that microneedle-puncture resulted in significantly less microbial
penetration compared to a hypodermic needle puncture. In addition, no microorganisms
crossed the viable epidermis in microneedle-punctured skin, in contrast to needle-punctured
skin [14].
Zeitter et al. have shown that in an animal model needling for four times in addition to skin care
induces an increased number of connective tissue fibers in the subepidermal layers [15].
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
10
In our study, 19 patients were treated with PRP dermaroller in three sessions. The microscopic
examination displayed with an increase of dermal fiber deposition of 44.25% after 8 weeks. In
addition, a significant increase in the number of dermal glands, epidermal papillae and
epidermal thickness was noted.
PRP is obtained from patient’s blood. Disease transmissions and immunogenic reactions are not
expected [16]. The procedure has been applied in different medical disciplines. It has been
described to be safe [17]. We also did not observe any side effects.
In conclusion, we report of significant skin changes that are noted in dermaroller treatment of
facial wrinkles. Especially PRP dermaroller treatment is a safe and effective cosmetic procedure
for facial skin rejuvenation.
The face of the patient has been published in accordance with her permission.
References
1. Fabbrocini, G., De Vita, V., Pastore, F., Annunziata, M.C., Caccuiapouti, S., Monfrecola,
A., Cameli, N., Tosti, N., Collagen induction therapy for the treatment of upper lip
wrinkles. Journal of Dermatological Treatment, 2012. 23:144–152.
2. El-Domyati, M., El-Ammawi, T.S., Moawad, O., El-Fakahany, H., Medhat, W., Mahoney
MG, Uitto, J., Efficacy of mesotherapy in facial rejuvenation: a histological and
immunohistochemical evaluation. Int J Dermatol, 2012. 51(8):913–919.
3. Gilchrest, B.A., A review of skin ageing and its medical therapy. British journal of
dermatology, 1996. 135:867-875.
4. Aust, M.C., Fernandes, D., Kolokythas, P., Kaplan, H.M., Vogt, P.M., Percutaneous
Collagen Induction Therapy: An Alternative Treatment for Scars, Wrinkles, and Skin
Laxity. Plastic and Reconstructive Surgery,2008. 121(4):1421-9.
5. Rachel, J.D., Jamora, J. J., Skin Rejuvenation Regimens: a profilometry and
histopathologic study. Arch Facial Plastic Surgery, 2003. 5(2):145-9.
6. Redaelli, A., Romano, D., Marcianó, A., Face and neck revitalization with platelet-rich
plasma (PRP): clinical outcome in a series of 23 consecutively treated patients. J Drugs
Dermatol, 2010. 9(5): 466-472.
Oyunsaikhan Surmaajav et al., diagnostic pathology 2017, 3:238
ISSN 2364-4893
DOI: http://dx.doi.org/10.17629/www.diagnosticpathology.eu-2017-3:238
11
7. Yuksel, E.P., Sahin, G., Aydin, F., et al. Evaluation of effects of platelet rich plasma on
human facial skin. Journal of Cosmetic and Laser Therapy, 2014. 16: 206–208.
8. Mehryan, P., Zartab, H., Rajabi, A., Pazhoohi, N., Firooz, A., Assessment of efficacy of
platelet-rich plasma (PRP) on infraorbital dark circles and crow’s feet wrinkles. Journal
of Cosmetic Dermatology, 2014. 13(1):72-78.
9. Man, D., Plosker, H., Winland-Brown, J.E., The use of autologous platelet-rich plasma
(platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast
Reconstr Surg, 2001. 107(1):229-37.
10. Jeon, I.K., Chang, S.E., Park, G.H., Roh, M.R., Comparison of Microneedle Fractional
Radiofrequency Therapy with Intradermal Botulinum Toxin A Injection for Periorbital
Rejuvenation. J Dermatology, 2013. 227(4):367–372.
11. Lee, H.J., Lee, E.G., Kang, S., Sung, J.H., Chung H.M., Kim, D.H., Efficacy of Microneedling
Plus Human Stem Cell Conditioned Medium for Skin Rejuvenation: A Randomized,
Controlled, Blinded Split-Face Study. Ann Dermatol, 2014. 26(5):584-91.
12. El-Domyati, M., El-Ammawi, T.S., Medhat, W., et al. Electro-optical synergy technique: a
new and effective non-ablative approach to skin aging. J Clin Aesthet Dermatol, 2010.
3:22–30.
13. Shin, M.K., Lee, J.H., Lee, S.J., Kim, N.I., Platelet-Rich Plasma Combined with Fractional
Laser Therapy for Skin Rejuvenation. Dermatol. Surg, 2012. 38: 623–630.
14. Donnelly, R.F., Singh, T.R., Tunney, M.M., Morrow, D.I., McCarron, P.A., et al.
Microneedle Arrays Allow Lower Microbial Penetration Than Hypodermic Needles In
Vitro. Pharm Res, 2009. 26(11): 2513–2522.
15. Zeitter, S., Sikora, Z., Jahn, S., Stahl, F., Strau, S., Lazaridis, A., Reimers, K., Vogt, P.M.,
Aust, M.C., Microneedling: Matching the results of medical needling and repetitive
treatments to maximize potential for skin regeneration. Burns, 2014. 40:966-973.
16. Dhillon, R.S., Schwarz, E.M., Maloney, M.D., Platelet-rich plasma therapy – future or
trend? Arthritis Res Ther, 2012. 14: 219.
17. Anitua, E., Orive, G., Aguirre, J.J., Ardanza, B., Andia, I., 5 year clinical experience with
BTI dental implants: risk factors for implant failure. J Clin Periodontol, 2008. 35:724 –
732.
