COSMETIC
Platelet-Rich Plasma with Basic Fibroblast
Growth Factor for Treatment of Wrinkles andDepressed Areas of the Skin
Tatsuro Kamakura, M.D.
Jiro Kataoka, M.D.
Kazuhiko Maeda, M.D.
Hideaki Teramachi, M.D.
Hisayuki Mihara, M.D.
Kazuhiro Miyata, M.D.
Kouichi Ooi, M.D.
Naomi Sasaki, M.D.
Miyuki Kobayashi, M.D.
Kouhei Ito, M.D.
Tokyo, Yokohama, Sapporo, Osaka,
Fukuoka, Hiroshima, and Atami, Japan

Background: There are several treatments for wrinkles and depressed areas of
the face, hands, and body. Hyaluronic acid is effective, but only for 6 months
to 1 year. Autologous fat grafting may cause damage during tissue harvest.
Methods: In this study, patients were injected with platelet-rich plasma plus
basic fibroblast growth factor (bFGF). Platelet-rich plasma was prepared by collecting blood and extracting platelets using double centrifugation. Basic fibroblast growth factor diluted with normal saline was added to platelet-rich plasma.
There were 2005 patients who received platelet-rich plasma plus bFGF therapy.
Results: Of the 2005 patients treated, 1889 were female and 116 were malepatients; patients had a mean age of 48.2 years. Treated areas inlcuded 1461
nasolabial folds, 437 marionette lines, 1413 nasojugal grooves, 148 supraorbital
grooves, 253 midcheek grooves, 304 foreheads, 49 temples, and 282 glabellae.
Results on the Global Aesthetic Improvement Scale indicated that the level ofpatient satisfaction was 97.3 percent and the level of investigator satisfaction
was 98.4 percent. The period for the therapy’s effectiveness to become apparent was an average of 65.4 days. Platelet-rich plasma plus bFGF therapy resulted
in an improved grade on the Wrinkle Severity Rating Scale. Improvement was
0.55 for a Wrinkle Severity Rating Scale grade of 2, 1.13 for a Wrinkle Severity
Rating Scale grade of 3, 1.82 for a Wrinkle Severity Rating Scale grade of 4,
and 2.23 for a Wrinkle Severity Rating Scale grade of 5.
Conclusions: Platelet-rich plasma plus bFGF is effective in treating wrinkles
and depressed areas of the skin of the face and body. The study revealed thatplatelet-rich plasma plus bFGF is an innovative therapy that causes minimal
complications. (Plast. Reconstr. Surg. 136: 931, 2015.)
CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Various therapies are available for treatmentof wrinkles and depressed areas of the skin.
The world’s most preferred therapy fortreatment of wrinkles and depressed areas of theskin is hyaluronic acid injection.1–3 However, hyaluronic acid is only effective for 6 to 12 months;
therefore, periodic treatment is required for thetreatment to remain effective.4
Another cosmetic surgery option for treating
wrinkles or depressed areas of the skin is fat injection. Fat injection is already a standard surgicaltreatment,5,6 but it requires liposuction, whichcauses internal bleeding and swelling that lasts 2
to 3 weeks.

Action and Therapeutic Effectiveness of
Platelet-Rich Plasma
Platelet-rich plasma is widely used to promote
tissue repair because it contains and releases various growth factors that heal tissue.7–10 Platelet-richplasma is also used to rejuvenate the skin. Plateletrich plasma improves the texture of the skin, butthere are limits to the effect it has on deep wrinkles. Platelet-rich plasma must be combined with
fat grafting to stimulate tissue growth.7,11
Several studies have indicated the usefulnessof basic fibroblast growth factor (bFGF).12–15 Clinical studies involving the skin used bFGF in combination with skin grafts to treat burns and to treat

From the the Seishin Plastic and Aesthetic Surgery Clinic.
Received for publication January 5, 2015; accepted April
23, 2015.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001705

Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

www.PRSJournal.com

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Plastic and Reconstructive Surgery • November 2015
chronic skin ulcers.16–18 However, very few clinicalstudies have reported using bFGF to treat wrinkles
and depressed areas of the skin.
No studies have reported adding bFGF toplatelet-rich plasma to treat wrinkles or depressed
areas of the skin in more than 1000 patients. The
purpose of the current study was to verify thesafety and efficacy of using platelet-rich plasma
plus bFGF to treat wrinkles and depressed areasof the skin.

PATIENTS AND METHODSThis study was conducted according to theprinciples of the Declaration of Helsinki. Informed
consent for platelet-rich plasma plus bFGF therapy was obtained from all patients before treatment. This is a retrospective study that included
primarily patients with wrinkles and depressed
areas. Cancer patients or patients who had a personal history of cancer, blood platelet disorders,or coagulation disorders were excluded.
From January of 2008 to December of 2011,
we evaluated and treated 2005 patients who had
wrinkles or depressed areas of the skin with platelet-rich plasma plus bFGF. Of these 2005 patients,
1889 were female and 116 were male patients.
Patients had an average age of 48.2 years (range,
17 to 84 years). All patients had only one treatment
within 6 months. A total of 4815 areas treated,with an average treatment number of 1.33, highlighting that different areas were treated at thesame time (Table 1).
Methods
Platelet-rich plasma was prepared by collecting blood and extracting platelets using double
centrifugation. We collected 9 ml of blood andcreated 1 ml of platelet-rich plasma. In the firstround, centrifugation was performed at 1800 rpm
Table 1. Number of Areas Treated with Platelet-Rich
Plasma plus bFGF Therapy
Site
Nasolabial foldMarionette line
Nasojugal groove
Supraorbital groove
Midcheek groove
ForeheadTempleGlabella
Perioral lip wrinkle
Neck
Back of the hand
Other

No. of Cases

Typical Injection
Volume (ml)

1461
433
1413
148
253
304
49
282
134
54
27
257

2.0–2.5
1.0–1.4
0.5–0.8
1.0–2.0
1.0–1.6
2.0–4.0
2.0–3.0
0.4–0.8
0.4–0.6
1.2–2.4
4.0–8.0
Dependent on areafor 10 minutes, after which the top layer of plasma
was collected. In the second round, centrifugation
was performed at 3200 rpm for 10 minutes, after
which the buffy coat and bottom layer of plasma
were collected. The bFGF used was Trafermin from
Kaken Pharmaceutical Co., Ltd. (Tokyo, Japan).
Two hundred micrograms of bFGF was diluted
with normal saline, and 10 to 20 μg of bFGF was
added per milliliter of platelet-rich plasma.
Evaluation and Statistical Analyses of Results
The Global Aesthetic Improvement Scale wasused to assess patient and physician satisfaction
with the treatment. Global Aesthetic Improvement Scale scores were determined up to 180
days after treatment. A score of 3 or higher wasdeemed to indicate that the treatment was effective and met with satisfaction. If the patient was
treated in multiple areas, each area was assessed
separately. This study was performed within thenine clinics in our practice by multiple physicians.
Satisfaction was measured by each physician andtheir patients. To minimize physician bias, theauthors reviewed patient satisfaction.
The effectiveness of platelet-rich plasma plus
bFGF becomes evident over time, and the inflection point at which that effectiveness becomesapparent varies from patient to patient andbecomes clearer over time. However, as patient
visits occur at irregular intervals, verification thatthe treatment has been successful becomes moredifficult. Assessment of such clinical outcomes
after treatment is similar to calculating the survival rate after cancer therapy. Thus, the KaplanMeier method was used to determine the pattern
in which the therapy’s effectiveness became
evident. The generalized Wilcoxon test (PetoPrentice method) was used to test for statisticallysignificant differences with respect to age andareas treated.

RESULTS
Patient satisfaction was 97.3 percent and physician satisfaction was 98.4 percent (Fig. 1). A
Global Aesthetic Improvement Scale score of 3
or higher was deemed to indicate that the treatment was effective. Patients were compared by
the rate at which the therapy’s cumulative effectiveness became evident, which was defined as
the time from first treatment to the first sign ofclinical effect. As mentioned above, the therapy’s
cumulative effectiveness became more evident
over time (Fig. 2).

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Volume 136, Number 5 • Treatment of Wrinkles and Depressed Areas

Fig. 1. Chart showing patient satisfaction (blue) and investigator satisfaction (red).

The Wrinkle Severity Rating Scale was used
to evaluate wrinkles before treatment, and theperiod for the therapy’s effectiveness to become
evident was evaluated by Wrinkle Severity Rating Scale grade. The therapy’s effectivenessbecame evident in an average of 60.4 days forwrinkles with a grade of 2, in an average of 64.8
days for wrinkles with a grade of 3, in an average of 66.6 days for wrinkles with a grade of 4,
and in an average of 70.8 days for wrinkles witha grade of 5. There was no significant difference, but the lower the Wrinkle Severity Rating
Scale grade, the earlier the patient satisfaction(Fig. 3).
Changes in the Wrinkle Severity Rating Scale
grade before and after treatment were examined.
The endpoint for treatment was determined to bewhen patient satisfaction was a Global Aesthetic
Improvement Scale score of 3 or more within 6months. Improvement for wrinkles with a Wrinkle
Severity Rating Scale grade of 2 before treatment
was 0.55, improvement for wrinkles with a Wrinkle
Severity Rating Scale grade of 3 before treatment
was 1.13, improvement for wrinkles with a Wrinkle
Severity Rating Scale grade of 4 before treatment
was 1.82, and improvement for wrinkles with a
Wrinkle Severity Rating Scale grade of 5 before
treatment was 2.23. These results revealed that thetherapy provided acceptable improvement evenfor wrinkles with a high Wrinkle Severity Rating
Scale grade (Table 2).
Typical results are shown in Figures 4 through8. This treatment appears to have an early expression period and a long-lasting effect.
A known material complication of treatment
is overcorrection, and this tended to increaseover time. Nonetheless, the overall incidenceof overcorrection has decreased steadily over
the observed years. By 2011, the incidence
had decreased to approximately 1.5 percent(Fig. 9). This decrease was mainly attributableto greater ability to adjust the amount of bFGF,
the platelet-rich plasma plus bFGF dose, andthe injection site.

DISCUSSION
Various treatments are used to treat wrinkles
or depressed areas of the skin that accompany
aging.1–3 The world’s preferred treatment is hyaluronic acid. However, hyaluronic acid is only
effective for 6 to 12 months; thus, periodic treatment is required for the treatment to remain
effective.4
Fat injection is a standard surgical option
for treating wrinkles or depressed areas of theskin.5,6 However, liposuction is required to collect fat for injection, which can cause internal933
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Plastic and Reconstructive Surgery • November 2015

Fig. 2. Graph showing the time after treatment and changes in patient satisfaction. GAIS,
Global Aesthetic Improvement Scale.

Fig. 3. Graph showing the time after treatment and satisfaction by grade on the
Wrinkle Severity Rating Scale (WSRS) before treatment. A Wrinkle Severity Rating
Scale grade of 2 is shown in blue, a grade of 3 is shown in red, a grade of 4 is shownin green, and a grade of 5 is shown in yellow.

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Volume 136, Number 5 • Treatment of Wrinkles and Depressed Areas
Table 2. Improvement in Wrinkle Severity Rating
Scale Grade after Platelet-Rich Plasma plus bFGF
Treatment Compared with before Treatment
WSRS Grade before Treatment
2345Change in WSRS Grade
0.55
1.13
1.82
2.23

WSRS, Wrinkle Severity Rating Scale.

bleeding and swelling that lasts for up to 2 to
3 weeks. As other lasting fillers have complications, risk becomes an issue.19 Platelet-richplasma plus bFGF can cause internal bleeding
and swelling for a period of less than 1 week andthe therapy is demonstrating a lasting effect.
These qualities make platelet-rich plasma plus
bFGF an extremely exceptional therapy.
Platelet-rich plasma is widely used to promote tissue repair, as it contains and releases
various growth factors.7–10 Studies have shownthat platelet-rich plasma improves the textureof the skin and helps skin to recover after being
subjected to a fractional laser.20–22 Nevertheless,there are limits to the effect that platelet-richplasma alone can have on deep wrinkles, andplatelet-rich plasma often is combined with fat
grafting to treat skin defects or depressed areasof the skin.7,11
The current study combined and injected
bFGF and platelet-rich plasma to repair wrinkles and depressed areas of the skin. The current authors previously treated patients withplatelet-rich plasma alone, but found thatplatelet-rich plasma alone was often ineffective. Furthermore, if platelet-rich plasma alone
was effective, it failed to treat deep wrinkles ordepressed areas of the skin. Fibroblast growth
factor has an effect on the dermis and fat areasand increases the volume of collagen, hyaluronic acid, and fat. Kawazoe and Kim reported
that platelet-rich plasma plus bFGF effectively
stimulated tissue growth.15 Nevertheless, few
clinical studies have reported use of plateletrich plasma plus bFGF.
Platelet-rich plasma plus bFGF is notinstantaneously effective, and its effectivenessbecomes evident over time. Overall, patient
treatment took an average of 65 days (median,
47 days) until patients were satisfied. The pointof patient satisfaction differed depending on
treatment area and the patient’s age and sex,
but approximately 98 percent of patients weresatisfied after 6 months of treatment. AlthoughFig. 4. Patient 1, a 39-year-old woman. Platelet-rich plasma
plus bFGF was injected into the patient’s nasojugal grooves
and midcheek grooves (right, 1.3 ml; left, 1.5 ml). (Above)
Before treatment. (Center) One month after treatment.
(Below) Four years 7 months after treatment. The grooves
were deep before treatment, but 1 month after treatment, the therapy’s effectiveness was already evident. The
patient’s grooves were effectively filled. Moreover, thetreatment remained effective 4 years 7 months later, andthere was no combination treatment performed during thisperiod.

there are individual differences in the point at
which treatment is determined to be effective,

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Plastic and Reconstructive Surgery • November 2015

Fig. 5. Patient 2, a 51-year-old man. Platelet-rich plasma plus bFGF was injected into the patient’s nasojugal grooves andmidcheek grooves (right, 1.5 ml; left, 1.7 ml). Hyaluronic acid was injected simultaneously for rhinoplasty. (Left) Before treatment. (Right) One and one-half months after treatment. This patient underwent rhinoplasty using hyaluronic acid at thesame time. Deep grooves were apparent before treatment, and 1.5 months after treatment the therapy was already effective.

Fig. 6. Patient 3, a 50-year-old woman. Platelet-rich plasma plus bFGF was injected into the patient’s upper eyelids (right,
0.3 ml; left, 0.3 ml), nasojugal and midcheek grooves (right, 0.6 ml; left, 0.7 ml), and nasolabial folds and marionette lines(right, 1.0 ml; left, 1.0 ml). (Above, left) Before treatment. (Above, right) Two and one-half months after the first treatment. The
patient underwent subbrow blepharoplasty 1 year 2 months after initial treatment. (Below, left) One year 5 months after the
first treatment and before the second treatment. This patient received platelet-rich plasma plus bFGF for the temple (right,
1.0 ml; left, 1.0 ml), forehead (1.5 ml), glabella (0.5 ml), and left nasolabial fold (0.3 ml) as a second treatment 1 year 5 months
after the first treatment. Those grooves and depressed areas were obvious before the second treatment. (Below, right) Ninemonths after the second treatment.

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Volume 136, Number 5 • Treatment of Wrinkles and Depressed Areas

Fig. 7. Patient 4, a 29-year-old woman. Platelet-rich plasma plus
bFGF was injected into the nasojugal grooves (right, 0.6 ml; left,
0.6 ml). (Above) Before treatment. (Center) Fifteen days after
the first treatment. (Below) Five years 7 months after the firsttreatment.

most patients were ultimately satisfied with treatment effectiveness.
This study verified the safety and efficacy ofplatelet-rich plasma plus bFGF therapy within a
6-month period. The therapy was markedly effective in most patients, displayed exceptional efficacy, and was deemed safe. The current authors
have used this therapy for over 6 years. Basedon clinical experience, platelet-rich plasma plus
bFGF therapy remains effective for 3 years or longer. Further studies are needed to verify this duration of action and to assess the long-term safety ofthe therapy.

Fig. 8. Patient 5, a 35-year-old man. Platelet-rich plasma plus
bFGF was injected into the nasojugal grooves (right, 0.5 ml;
left, 0.5 ml). (Above) Before treatment. (Center) Four months
after the first treatment. (Below) Seven years after the firsttreatment.

Injecting a mixture of platelet-rich plasma
and fibroblast growth factor increases the volume of not only the skin but also adipose and the
subcutaneous tissue. This treatment is therefore
assumed to last a long period because of the large
volume increase to different tissue planes. We
plan to report medium- and long-term results inthe next phase of the report.

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Plastic and Reconstructive Surgery • November 2015

Fig. 9. Changes in the incidence of overcorrection by year.

CONCLUSIONS
A main complication of this treatment was
overcorrection. The dose of platelet-rich plasma
plus bFGF is crucial to prevent overcorrection. With hyaluronic acid use, the volume of
injected hyaluronic acid is roughly equivalent
to the volume of tissue growth. For plateletrich plasma plus bFGF therapy, predicting theamount of tissue growth in response to theamount of platelet-rich plasma plus bFGF is ofutmost importance. The injection amount must
be determined with some level of overreaction
in mind, as responses will have individual differences. Physician experience is an importantfactor in making the determination of the correct injection amount. The amount of bFGF inplatelet-rich plasma plus bFGF is the key stepin preventing overcorrection, as adding morebFGF will stimulate more tissue growth, and may
also therefore cause an overcorrection. As such,using a smaller amount of bFGF reduces theprobability of overcorrection.
Tatsuro Kamakura, M.D.
Seishin Plastic and Aesthetic Surgery Clinic
Pyramide 2F, 6-6-9 Roppongi, Minato-ku
Tokyo 106-0032, Japantatsu@biyougeka.com

patient consent

Patients provided written consent for the use of theirimages.

acknowledgments

The authors are deeply grateful to Yuichiro Kizuka,
Takanori Nakatsuji, Makoto Nishida, Tetsuro Ito, andDaisuke Kato for collecting the data used in this study.
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