A Personalized Nutrition Plan Improves Outcomes of Facial Regeneration With Platelet-rich Fibrin Liquid Matrixes

Background: The importance of nutrition in the prevention of skin ageing has been shown by large observational studies. Despite this fact, there are no studies assessing dietary changes as adjunct procedures to aesthetic interventions. The objective of this manuscript is to study whether a personalized nutritional plan conveys additional benets to Platelet-Rich Fibrin (PRF) facial regeneration Methods: Forty seven healthy women (mean age 52.5 years old) were offered minimally invasive facial regeneration with the use of PRF liquid matrixes, as well as a personalized nutritional plan. The nutritional plan was informed by a nutrigenetic test based on 128 polymorphisms. Horizontal forehead lines, zygomatic wrinkles or mid-cheek furrows, nasolabial folds, perioral expression wrinkles, and marionette line were assessed separately with the use of the Facial Wrinkles Assessment Scale (FWAS) Results: Total FWAS scores change was statistically signicantly better in women who reported an at least partially adaptation of nutritional recommendations for a 3-month period or longer (z=2.4, p=0.008). Conclusions: Personalized nutritional recommendations based on individual needs as well as on generally accepted dietary guidelines can improve treatment outcomes of minimally invasive facial skin aesthetics interventions.


Background
Over the last decade, the use of autologous blood concentrates, such as platelet-rich plasma (PRP) and platelet-rich brin (PRF), has gained importance in aesthetic medicine for dermal stimulation, augmentation, and rejuvenation. (1)(2)(3). Platelet-rich brin liquid matrices based on the low speed centrifugation concept have shown effectiveness in facial regeneration (4,5) and are being increasingly applied in facial aesthetics either alone or in combination with other techniques. At the same time, studies of cells in the laboratory, animal models and human trials also support roles for a variety of nutrients in preventing skin ageing (6). Large observational studies have suggested associations of vitamin C, linoleic acid, green and yellow vegetables with younger-looking skin (7,8) indicating the need of more holistic approaches that incorporate nutritional advices into aesthetic treatments.
Personalized nutrition plans informed by knowledge of an individual's DNA are increasingly being utilized for health as well as general well-being purposes. Adherence to a nutritional plan that conforms to standard dietary guidelines and at the same time take into account the various individual needs may improve healthy skin parameters. In this study we sought to investigate whether a personalized nutrition plan convey additional bene ts to a minimally invasive technique for facial regeneration.

Methods
A total of 47 otherwise healthy women offered PRF facial regeneration based on the low-speed centrifugation concept were included in the study. An ethical approval was granted by the Ethical and Scienti c Committee of the Plastic and Reconstructive Surgery Department of Agioi Anargyroi General Oncological Hospital of Ki sia, Athens, Greece (No 1/26/09/2016) and the patients signed an informed consent prior to their treatment. All patients were treated by the same experienced physician (CN) using a standard protocol described in more detail in previous publications (4,5). Brie y, four sessions of PRF treatments were offered with 2-to 3-week intervals. In each session, 60 mL of venous blood was collected in 10 mL PRF tubes (Orange tubes, Process for PRF, Nice, France) and centrifuged according to the following protocols.
Using a preprogramed centrifuge with a radius of 110 mm (Process for PRF, Nice France) producing a total of 12-13 mL PRF of reduced density. PRF liquid matrixes produced by the two abovementioned centrifugation protocols were mixed and a full face injection technique was applied as described previously (5).
Α personalized nutritional plan was offered by a specialized nutritionist during the treatment. A nutrigenetic test was utilized to aid personalized nutritional recommendations. In more detail, prior to the rst PRF session, additional 5 mL of vein blood was collected for genomic DNA analysis using a Pure Link Genomic DNA Mini Kit Assay (Life Technologies), according to the manufacturer's instructions.
Adaptation of the nutritional recommendations was assessed with a simple questionnaire provided at the time of facial reassessment. In more detail, participants were asked whether they adapted any dietary changes ("none", "some" and "all or the majority") and for how long ("1-3weeks", "1-2 months", "3-4 months", "5-6 months"). An at least partially adaptation of recommendations for a 3-month period or longer was regarded as adherence to dietary recommendations.
Horizontal forehead lines, zygomatic wrinkles or mid-cheek furrows, nasolabial folds, perioral expression wrinkles, and marionette line were assessed separately with the use of the Facial Wrinkles Assessment Scale (FWAS), a simple and reliable tool for the assessment of wrinkles (35). Two authors (CN, AMV) blinded to "adherence on recommended diet" scored the scales prior to initial intervention and at a followup visit which took place about 6 months upon the completion of the four PRF sessions.

Statistical analyses.
Study participants were divided into two groups: those who reported an at least partial adherence to dietary recommendations for the majority of the time (group A) and the rest (group B). Changes in FWAS scores were compared with Mann-Whitney U Test. Unpaired t-tests were utilized for normally distributed variables and chi-squared test for nominal data. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request

Results
In all, 43 out of 47 patients completed the study: Two patients ceased treatment; one for nancial reasons and the other due to the level of perceived pain associated with treatment. Another was lost in the follow up. The forth patient reported a health problem (gynaecological cancer) which has not been reported during the PRF treatment and was excluded from the study.

Discussion
Blood concentrates are increasingly being utilized as autologous products for aesthetic purposes because they contain platelets for growth factor release, brin scaffold for tissue remodelling, plasma proteins for collagen synthesis, white cells for in ammation and recovery, and stem cells for tissue repair and regeneration. Their outcomes regarding rejuvenation of photo aged facial skin has been shown in small trials (4,36).
This study was not intended to verify previous positive outcomes. In other words, whether surgeons' reported improvement in wrinkles scores is a biased or a true effect is beyond the scope of this observational study. A more appropriately designed study for this purpose has already been reported previously with positive results (4). Current study was performed with the intention to see whether a personalized nutritional plan has an impact on PRF facial regeneration outcomes. For this reason, scorers were blinded to adherence to this plan. Thus the additional skin aesthetics bene ts conveyed by the dietary recommendations cannot be attributed to observer bias An increasing amount of evidence suggests a protective effect of "healthy diet" on skin ageing. Current dietary recommendations promote higher intakes of fruit and vegetables and sh and PUFAs (37,38). Nevertheless, several studies over the past few years have shown that what constitutes a healthy diet for an individual depends to some extent on his or her physiology and lifestyle (39)(40)(41)(42). Individualized nutrition advice, informed by knowledge of genetic variants, are more and more favoured over standard dietary guidelines based on population-wide averages (43).
Whether a personalized approach based on genotyping results conveys additional bene ts over current nutritional recommendations in skin aesthetics, obesity, and other health issues is under study by various teams around the world. Regarding facial skin aesthetics, this study conforms to previous indicating a bene cial middle or long term effect of healthy nutrition (7,8). In our cases, the inclusion of genetic variants helped the speci cation of general dietary recommendation that quite often propose a wide range of concentrations regarding macro-and micronutrients. This means that our personalized nutritional plans conformed to "healthy diet" and the proposed optimal nutrition intake to stave off skin ageing. In addition, the exact amounts of the various nutrients were further speci ed based on the genotype as exempli ed above.
Assessment of all potential exposure variables as well as the various determinants of skin aging and appearance require hundreds or thousands of subjects. Nevertheless, as this study shows, nutritional interventions are potentially an important element in our era of minimally invasive and holistic care in facial aesthetics.

Conclusions
To our knowledge this is the rst study that includes a nutritional intervention as an adjunct procedure to facial aesthetic interventions Overall, our data indicates that nutritional recommendations based on individual needs can improve treatment outcomes and should be considered as an integral part of comprehensive care in facial aesthetics.

Declarations
Ethics approval and consent to participate The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests
KG is the owner of Embiodiagnostics laboratory that provides a range of comprehensive genomic services to assist individuals to reach decisions on diet and lifestyles based on their DNA pro le. The remaining authors disclose no con ict of interest.
Authors' contributions CN, KG and IV designed the study; CN treated the patients; KG performed the molecular biology experiments and provided the nutrigenetic results; EL offered the individualized nutritional plans; AMV assisted with data recording; DC and KG supervised the whole process. CN, KG, IV, and AMV wrote and DC revised the initial draft.