185
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
AGING MANAGEMENT WITH THE USE OF EXOSOMES, PRP/
PRF WITH ALBUMIN GEL (PLASMA GEL) AND ASSOCIATED
TECHNIQUES IN OROFACIAL HARMONIZATION TREATMENT
Adelaide Maso1
Abstract: Aging, it is a physiological process that involves a progressive decline in the function
of the organs, with loss of homeostasis and increased likelihood of disease disease and death. This
account focuses on the classic perspectives on the biogenesis of exosomes, and age-related associated
changes. Due to its ability to transmit biological information between cells, this work also discusses
the interaction of mesenchymal cell exosomes, as a potent adjuvant in the treatment of association of
orofacial harmonization techniques. The demand for aesthetic and rejuvenating treatments is increasing
in society, thus, each day, the demand for orofacial harmonization increases exponentially in order to
slow aging. Orofacial harmonization is a set of procedures performed by the dentist, which aims at the
aesthetic and functional balance of the face. Exosomes are membranous extracellular vesicles ranging
from 30 to 200 nm in diameter. Exosomes has been found to be secreted by most cell types, including
immune cells (B cells, T cells, mastocytes, dendritic cells), neuronal cells, epithelial cells, endothelial
cells, embryonic cells, cancer cells and cells mesenchymal trunk (mscs). The search for youth and
perfect skin is a natural desire for the human being. And in this way, collagen biostimulation stands
out as a safe and eective option to rejuvenate the skin, ghting the signs of aging and promoting
a rmer, toned and radiant appearance. Research in exosomes therapies continues to prosper.
Subsequent data on indications, dose response, safety, eectiveness and ability to combine therapy
with exosomes as a “skin primer” for biostimulation techniques, such as calcium hydroxylapatite
1 Specializing in Regenerative Medicine - Lennational Society for Stern Cell Application (ISSCA), Master in
Dental Medicine - Fernando Pessoa University (Porto- Portugal), specialist in Nutraceutic and Hormonal Health - FACOP
São Paulo Specialist in Advanced Oral Surgery - São Leopoldo Mandic - São Paulo, Postgraduate in Orthodontics and
Functional Orthopedics - Sboom -Sao Paulo Post Graduated in Orofacial Harmonization (Inaesp -Brasil), Post Graduated
in Ozonotherapy Isla - Portugal Graduated in UNG Dentistry - São Paulo
186
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
(CAHA), platelet rich plaketers (PRP) and brin matrix Platelet plasma, (PRFM) is growing rapidly.
Keywords: exosomes, facial rejuvenation, orofacial harmonization, collagen bio -stomulator, PRP -
plaquette plasma.
INTRODUCTION
Facial aging is a multifactorial process that has been widely studied, changes in the skin in
the facial skeleton and soft tissues are considered the pillars of aging. (LUVIZUTO; QUEIROZ., 2019).
The intrinsic process of aging is characterized by decreased skin collagen, decreased elastin
and hyaluronic acid (AH), which generates a decreased thickening of the skin and loss of elasticity.
(MASO, TRAMONTINI, 2023)
The discovery of extracellular vesicles (EVs) or exosomes dates back to the 1940s, and these
small vesicles were ignored as cellular trash bins for a long time (Théry et al., 2002)
Signicant attention came only in the mid-2000s, after the rediscovery of exosomes as
messengers of communication cells. Exosomes, and specically MSC-EXOS, have great potential for
promoting rapid and ecient wound healing. Exosomes can be applied directly to an injury, which in
animal models has shown to promote collagen synthesis and proliferation and migration of broblasts
and keratinocytes. These eects have been shown in part to the exosomic regulations of microorna
levels and protease activities. (HADE et al., 2021)
Exosomes are derived from mesenchymal stem cells (CTMs) and can be potentially used as an
alternative for cell therapy, wound treatment and angiogenesis aid. (Saheera et al., 2020)
Studies with treatments with exosomes continues to ourish. Subsequent knowledge around
indications, dose response, safety, eectiveness and ability to combine treatment with exosomes as a
“skin primer” - for bioestimulation modalities such as calcium hydroxylapatite (CAHA), platelet rich
plaketers (PRP ) and plasma rich in brin matrix (PRFM) is growing rapidly. (KALLURI et al., 2020)
187
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Aging is a complex and natural biological process that involves several dierent pathways with
genetic and environmental elements, which are studying with the decline of physical and mental abilities
over the years. The eects of aging occur on various systems of the body, including the endocrine
system, which is in the fall of various hormones, known as endocrinossenescence. (XU, 2012)
It is believed that the accumulation of molecular and stochastic cellular damage causes aging.
Although there is no precise denition of the exact type of damage responsible for aging -related
degeneration, it probably includes mitochondrial dysfunction, high levels of ros, telomeric friction,
changes in nuclear structure, accumulation of genetic mutations or DNA, proteins and membrane
damage. (Robbins, 2017).
Exosomes are involved in multiple physiological and pathological processes, including cell
senescence. Exosomes mediate cross-signaling and play a critical role in cell communications. Exosomes
have evolved as potential biomarkers for aging - related diseases.
Development
The skin
The skin is the largest organ in the human body, provides mechanical protection and plays an
important role in thermoregulagão, water control and exposure to external aggressions, as it is the largest
external clod is in constant exposure to environmental conditions. Consisting of three interconnected
layers, epidermis, dermis and hypodermis. (Perlingeiro, 2020).
In the skin, the aged aspect is represented by wrinkles and sagging and results from structural
changes at the molecular level. Modications in collagen, the most important protein of connective
tissue, were responsible for these anatomical changes. (FARIA, et al 1995).
The dynamics of skin metabolism is controlled by hormonal automatic functions, such as
hydration. In the skin, hormones are responsible for the synthesis of hyaluronic acid, and collagen
production. Anti -aging therapies and hormone replacement has been a complementary Authore
188
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
used by the scientic environment for a better result in treatment, according to studies the defense
of hormones at ideal levels, have a negative response to both health and individual’s skin and skin
(MASO, TRAMONTINI, 2023)
Epidermis
It originates in the Ectoderm embryonic leaet, its main function is coating and protection,
creating a selective barrier between the external environment and the adjacent connective tissue. Can
be divided into 4 strata or layers:
• Corneal layer,
• Granular layer
• Thorny layer
• Basal layer (LUVIZUTO, 2019).
The outermost layer of the skin, the epidermis of multiple cell layers, protects the skin from
toxins, bacteria and liquid loss through the corneal layer. Although the fundamental structure of the
skin is the same in all humans, there are signicant dierences in epicedermic architecture of the face
between dierent genres and ethnicities. (PERLINGERO, 2020).
The outermost layer of the skin, the epidermis of multiple cell layers, protects the
skin from toxins, bacteria and liquid loss through the corneal layer. Although the fundamental
structure of the skin is the same in all humans, there are signicant dierences in epicedermic
architecture of the face between dierent genres and ethnicities. (PERLINGERO, 2020).
Dermis
The dermis is the second main part of the skin, aging changes are aected in this layer, it is a
189
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
highly wear -elastic elastic fabric, it is located just below the epidermis, consists of cellular and chard
elements. It is in this layer that we nd from 70 to 80% of collagen bers. (PERLINGERO, 2020).
Fibroblast is the main cell present in the dermis, which is responsible for the synthesis of the
components of the extra cellular matrix (MEC), such as collagen, elastic and reticular bers. Plays a
fundamental role in tissue regeneration. (LUVIZUTO, 2019).
The dermis is divided into three portions:
• Papillary, outermost.
• Reticular, more internal and dermis perianexial. (LUVIZUTO, 2019).
Hypodermis
The hioperm, the deepest layer of the skin, has a thickness that can range from a few millimeters
to several centimeters, and its thickness is extremely important in the analysis of facial aging from the
volumetric point of view. (Perlingeiro, 2020)
The subcoune tissue, a mesodermic product, is just below the skin. Hypodermis, which is
dened by microscopic anatomy as a subcutaneous fascia, is not part of the skin. Instead, it serves as a
link between the skin and other muscles and organs. (LUVIZUTO, QUEIROZ, 2019).
The subcutaneous screen is composed of a dense connective tissue ber network within it,
which connects the skin mime muscles to the skin, is divided into deep and supercial planes by the
aponeurotic muscle system. (Perlingeiro, 2020)
Microscopically, the hypodermis is composed of a lobby -like adipose tissue, which
serves as a thermal insulator and maintains caloric homeostasis. (LUVIZUTO, QUEIROZ, 2019)
Platelet aggregates: PRP/PRF for rejuvenation of skin
Platelet rich plasma (PRP) is an autologous biological product that It involves the injection of
190
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
activated platelets, which stimulate the release of growth factors, triggering broblast proliferation and
healing through the formation of new collagen, elastin and extracellular matrices. (Phoebe et al., 2024)
Platelet -rich brin (PRF) is an autologous membrane proposal that while imprisoning growth
factors, oers advantages in accumulating platelets and leukocytes in the host. But its faster resorption
properties (2 weeks) are limitations. Recent studies have shown that heating a poor platelet liquid plasma
layer (PPP) may extend the heated albumin resorption properties (albumin gel) from 2 weeks to more
than 4 months (E-PRF). (Fujioka, 2020)
Marx denes that platelet rich plasma (PRP) is an autologous plasma volume that has a platelet
concentration above the basal values. (MARX, 2001).
Platelets have a variety of growth factors, and seven growth factors were described by Marx in
2001. Since then, more than 1500 growth factors and regulatory proteins are responsible for the eects
of PRP. (Marx., 2001).
By producing platelet gel, the centrifugation of autologous venous blood results in a high
concentration of platelets in a relatively small volume of plasma, resulting in the formation of platelet
-rich plasma. This is a thrombin and calcium composed of platelet activation and at the beginning of the
coagulation step, resulting in platelet gel formation, rich in growth factors such as PDGF, TGF-BETA,
EGF and VEFG besides IGF3-6.8 . (EPLEY, 2004)
Kolster reports that the mechanism of action happens due to some platelets to be activated
during the mechanical eect of centrifugation. A Liberation of growth factors occurs after endogenous
or exogenous activation of platelets and have a chemotatic eect as well as a direct and indirect eect
on tissue regeneration. Mononuclear leukocyte broblasts and mesenchymal stem cells are attracted to
PRP, and their proliferation is stimulated. (Kolster., 2020).
The literature provides indications that the ideal platelet concentration is approximately 2.5
times higher than basal values, and the higher secretion of endogenous hyaluronic acid, and type 1
procoliagen by skin broblasts was described in a concentration in this range. (Anitu et al., 2009).
191
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Exosomes
Exosomes are produced through the formation of intracellular multivesicular bodies with
intraluminal vesicles and double invagination of the plasmatic membrane. Exosome may contain
membrane proteins, cytosolic and nuclear proteins, extracellular matrix proteins, metabolites and
nucleic acids, namely MRNA, non -coding RNA and DNA species. (Kalli et al., 2020).
Exosomes are a type of extracellular vesicles (EVs) of nanometric size released by almost all
eukaryotic cells, which serve as mediators for intercellular communication and can be used as cell free
therapies. (DING et al., 2019)
Exosomes derived from mesenchymal cells (MSC) play a crucial role in modulating
inammatory and immunological response. Increasing evidence indicates that these exosomes promote
polarization of M1 phenotype macrophages, associated with pro-inammatory responses, to the M2
phenotype, which is characterized by the secretion of anti-inammatory factors such as IL-10 and
TGF-β. (Cunnane et al., 2018)
Mesenchymal trunk cells, which have the capacity for dierentiation and self -renewal, are
being studied in order to nd a clinical application in regenerative medicine.
Previous studies have shown that mesenchymal stem cells (CTMs) are capable
of self-renewal and multipotential dierentiation capacity, which demonstrates promising
therapeutic potential for tissue regeneration and skin function recovery. (McFarlin; et al 2006).
Exosomes released from dierent cell types contain dierent lipids and proteins. The lipid
composition of exosomes comprises lipids that are part of the plasma membrane and golgi, and are
enriched in glycoesngolipids, phosphatidilserine cholesterol and ceramide. (Friendrana, 1998)
Skin wound healing is characterized by the repair of injured tissue, being the regeneration orchestrated
by multiple cells to restore a protective barrier (Singer, 1998)
192
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Case report
Female patient, 78 years old leucoderm, presenting a skin with wrinkles, sagging, dehydrated
and tired appearance.
It sought orofacial harmonization treatment to improve the skin in general.
Main complaint wrinkles on the face and “aged and fallen”
Anamese, clinical examination, physical examination and evaluation of inammatory
parameters, and the falls of the face was performed.
In physical examination there was a abby, dehydrated skin with the presence of shar p wrinkles
in orrobital orrobial region.
Treatment
The treatment proposed and performed on the patient was a facial harmonization with various
procedures joined with exosomes.
Among them, botulinum toxin, lip lling with hyaluronic acid, biorevitalization of the skin
with exosomes, and alb-PRF collagen bio-stimulation associated with exosomes were performed.
After anamnesis and clinical examination, the diagnosis of starting the procedures was closed.
To perform the procedures, we divide the steps. At rst we performed the treatment with
botulinum toxin, did the hygiene of the skin with chlorhexidine, and apply at specic points to relax the
muscles.
After the 10th day, the biorevitalization of the skin was performed through microagulating with
the use of exosomes. Exosomes were applied in two ways, through microagulating and in conjunction
with the PRF and ALB PRF (plasma gel).
To obtain the PRP/PRF, the patient’s blood was collected, the full blood collected was from
peripheral region, in 9 ml plastic tubes and centrifuged at 1600 rpm for 5 minutes to a force g 200.The
193
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
sedimentation centrifugation In compact disc (CDC) uses a relatively low G force (about 200-500 g).
After that, the plasma layer was heated at 80 ° C for 10 minutes to create denatured albumin
(albumin gel). The remaining cells and the growth factor found in the leukocyte layer (liquid PRF)
were later mixed again with the cooled albumin gel to form ALB-PRF, and the same mixed with
reconstituted and injected exosomes on the facing face in specic regions using cannulas, thus aiming
an improvement in dermal thickness.
FINAL CONSIDERATIONS
Many elds of regenerative medicine use platelet concentrates because they can provide
supraphysiological concentrations of autologous platelets, leukocytes and growth factors. To accelerate
the formation of hard or soft tissues, regenerative medicine has used a variety of biomaterials, surgical
procedures and growth factors.
Exosomes, and specically mesenchymal cells, have great potential for promoting rapid and
ecient wound healing when associated.
Authors report that platelet-rich brin (PRF) is a regenerative biomaterial that is fully reabsorbed
in about 2 to 3 weeks. However, it has recently been shown that a new heating process prolongs PRP/
PRF working properties from 2 to 3 weeks to 4 to 6 months.
Entlyam, many authors report that, platelet-rich brin (PRF) has been characterized as a
regenerative biomaterial that is fully reabsorbed in a typical period of 2 to 3 weeks, but reports that a
new heating process has recently been demonstrated extends the properties. of the PRP/PRF work of a
standard period of 2 to 3 weeks for a duration of 4 to 6 months.
In order to have a good result and a good response and maintenance of aesthetic procedures
that it aims to achieve and maintain for longer, it is of fundamental importance to manage aging with
the use of safe and advanced techniques, guiding the patient as to the lifestyle and adequate feed and
supplementation.
194
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Taking into consideration of the articles and ndings in the present report, we can see the
importance of approaching the patient as a whole, and of emphasis that exosomes have also gained wide
attention in the eld of biomarkers research and are now seen as a strategy Alternative to regenerative
therapies based on stem cells.
Although exosomes have achieved signicant achievements in various therapies, the
challenges remain, as we nd in the literature numerous articles that report the use of exosomes and
their relationship with the skin, however, we need to perform more studies with this type of treatment
Clinical result before and after
195
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
REFERENCES
Amigorena S. Imunoterapia antitumoral usando exossomos derivados de células dendríticas. Pesquisa
em imunologia, 1998, 149.7-8: 661-662.
Anitua E , Sanchez M, Zalduendo MM, et al, (2009). Fibroblastic response to tratamento with dierent
preparations rich in growth factors Cell Prolif 42:162-170
Braz, André Vieira Atlas de anatomia e preenchimento global da face/André Vieira Braz, Thais
Harumi Sakuma. – 1. ed. – Rio de Janeiro : Guanabara Koogan, 2017. il. ISBN 978-85-277-3248-2
Coimbra DD, Uribe NC, Oliveira BS. “Quadralização facial” no processo do envelhecimento Surg
Cosmet Dermatol.2014;6(1):65-71
Cantor AJ, Clark RA. Cicatrização de feridas cutâneas. N Engl.J Med. 1999; 341(10):738-746.
Cunnane, E.M.; Weinbaum, J.S.; O’Brien, F.J.; Dorp, D.A. Future perspective on the role of stem
cells and extracellular vesicles in vascular tissue regeneration. Front. Cardiovasc. Med. 2018, 5, 86.
Ding J., Wang X., Chen B., Zhang J., Xu J. Exossomos derivados de células-tronco mesenquimais
da medula óssea humana estimuladas por deferoxamina aceleram a cicatrização de feridas
cutâneas promovendo angiogênese. BioMed Pesquisa Internacional . 2019; 2019:12. DOI:
10.1155/2019/9742765.9742765
Eppley BL, Woodell JE, Higgins J. Platelet quantication and growth factor analysis from platelet-
rich plasma: implications for wound heal ing. Plast Reconstr Surg. 2004;114(6):1502-8.
Faria JC, Tuma Júnior P, Costa MP, Quagliano AP, Ferreira MC. Envelhecimento da pele e colágeno
[Skin aging and collagen]. Rev Hosp Clin Fac Med Sao Paulo. 1995;50 Suppl:39-43. Portuguese.
PMID: 7659928.
FITZGERALD R, CARQUEVILLE J, YANG PT. Anapproach to structural facial rejuvenation with
llers in women.Int J Womens Dermatol. 2018;5(1):52-67
Fujioka-Kobayashi, M., Schaller, B., Mourão, CFDAB, Zhang, Y., Sculean, A., & Miron, RJ (2020).
196
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Caracterização biológica de uma mistura injetável de brina rica em plaquetas composta por gel de
albumina autóloga e brina líquida rica em plaquetas (Alb-PRF). Plaquetas , 32 (1), 74–81. https://
doi.org/10.1080/09537104.2020.1717455
FUJITA, T.; OHTANI, J.; SHIGEKAWA, M.; et al. Inuence of sex hormone disturbances on the
internal structure of the mandible in newborn mice. European Journal of Orthodontics, v. 28, n. 2, p.
190–194, 2006.
Hade, Mangesh D., Caitlin N. Suire e Zucai Suo. 2021. “Exossomos derivados de células- tronco
mesenquimais: aplicações em medicina regenerativa” Células 10, no. 8: 1959. https://doi.org/10.3390/
cells10081959
Kalluri R, LeBleu VS, Science The biology, function, and biomedical applications of exosomes.,
Ciência 367, 640 (2020) 7 de fevereiro de 2020 DOI:10.1126/science.aau6977
Kolster, Bernard C. Guia ilustrado para indução de colágeno com plasma rico em plaquetas /Bernard
C Kolster, Uwe Paascch- Nova Odessa , SP: Napoleão 2020
Luvizoto E, et al. Arquitetura Facial. 1ª ed.São Paulo: Napoleão Quintessence, 2019. 70p.
Marx RE, ( 2001) : Platelet Rich Plasma (PRP) What is PRP and what is not PRP? Implant Dent 10:25
-228
Maso A, Tramontini L. THE BENEFITS OF NANOSTRUCTURED TRANSDERMAL HORMONAL
REPLACEMENT THERAPY IN OROFACIAL HARMOZIZATION TREATMENT: CASE
REPORT. hs [Internet]. 2023 Jul. 6 [cited 2024 May 12]; 3 (03):103-24. Available from: https://
www.periodicojs.com.br/index.php/hs/article/view/1405
McFarlin K, Gao X, Liu YB, Dulchavsky DS, Kwon D, Arbab AS, Bansal M, Li Y, Chopp M,
Dulchavsky SA, et al. Reparação de Feridas Regen. 2006; 14(4):471–478.
Miron RJ, Pikos MA, Estrin NE, Kobayashi-Fujioka M, Espinoza AR, Basma H, Zhang Y. Extended
platelet-rich brin. Periodontol 2000. 2023 Nov 20. doi: 10.1111/prd.12537. Epub ahead of print.
PMID: 37986559.
197
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Perlingero A. Esculpindo Faces Ciência & Arte na Harmonização Orofacial. 1ª ed.São Paulo:
Napoleão, 2020 p 89-91
Pereira, F.F (2021) CAMADAS DA FACE E MUDANÇAS ASSOCIADAS COM O
ENVELHECIMENTO FACIAL Aesthetic Orofacila Science129AOS| Vol. 02 | n. 02| página 129a
143
Pereira M.M.Universidade Federal do Rio Grande do Norte Centro de ciências da Saúde,Programa de
Pós graduação em ciências Farmacêuticas - 2013
Pessa, JE, Zadoo VP, Mutimer KL, Haner C, Yuan C, DeWitt AI, Garza JR (2000) Relative maxillary
retrusion as a natural consequence of aging: combining skeletal and soft tissue changes into an
integratedmodel of midfacial aging. Plast Reconstr Surg102:205–212
Phoebe LKW, Lee KWA, Chan LKW, Hung LC, Wu R, Wong S, Wan J, Yi KH. Use of platelet
rich plasma for skin rejuvenation. Skin Res Technol. 2024 Apr;30(4):e13714. doi: 10.1111/srt.13714.
PMID: 38650371; PMCID: PMC11035968.
Pu C.M., Liu CW., Liang CJ ., et al. Revista de Dermatologia Investigativa .2017; 137(6):1353-1362.
DOI: 101016/j.jid 016.12.030.
Robbins P D. Vesículas extracelulares e envelhecimento. Investigação de Células- Tronco. 2017 Dez
19;4:98. DOI: 10.21037/sci.2017.12.03. PMID: 29359137; PMCID: PMC5762993.
ROHRICH RJ, AVASHI YJ, Ira L. SAVETSKY IL. Prediction of Facial Aging Using the Facial Fat
Compartments. Plast. Reconstr. Surg. 2021; 147: 38S.
Saheera S, Potnuri AG, Krishnamurthy P. Nano-Vesicle (Mis)Communication in Senescence-Related
Pathologies. Cells. 2020 Aug 26;9(9):1974. doi: 10.3390/cells9091974. PMID: 32859053; PMCID:
PMC7564330.
Stremersch S., Vandenbroucke RE, Van Wonterghem E., Hendrix A., De Smedt SC, Raemdonck K.
Comparando vesículas semelhantes a exossomos com lipossomas para a entrega celular funcional de
pequenos RNAs. J. Controle. Liberar. 2016; 232 :51–61. doi: 10.1016/j.jconrel.2016.04.005.
198
ISSN: 2763-5724 / Vol. 04 - n 03 - ano 2024
Théry C., Zitvogel L., Amigorena S. Exossomos: Composição, biogênese e função. Nat. Rev. 2002;
2 :569–579. doi: 10.1038/nri855.
Witwer KW, Buzás EI, Bemis LT, Bora A, Lässer C, Lötvall J, Nolte-’t Hoen EN, Piper MG, Sivaraman
S, Skog J, Théry C, Wauben MH, Hochberg F. Standardization of sample collection, isolation and
analysis methods in extracellular vesicle research. J Extracell Vesicles. 2013 May 27;2. doi: 10.3402/
jev.v2i0.20360. PMID: 24009894; PMCID: PMC3760646.
Xu D, Tahara H. O papel dos exossomos e microRNAs na senescência e envelhecimento. Adv Droga
Deliv Rev 2013; 65:368-75. 10.1016/j.addr.2012.07.010
