Has anyone had any experience using platelet rich autologous plasma for rejuvenation?

It apparently has a track record in orthopedics and wound healing and these applications are being used to underpin its claims as a skin rejuvenator. It's a substantial investment for the patient. Does it work?

I started a forum on PRP on this site some months ago and no one knew anything about it. Very big in Europe I hear (Kylie Minogue has had treatment in Italy). It is becoming big here in Australia where I am. I have treated several patients so far and mixed results - but you do need more than one treatment and 3 months for results, and I haven't had time to do that full schedule on anyone yet.. I treated one ladies neck 1 month ago and awesome result from one treatment - skin much much tighter and smoother. The nice thing is its sooo simple and no risk of infection or allergy as autologous.

PS - Substantial investment??? Price should equate to botox/fillers/lasers etc. We charge AUS$330 a test tube - which will treat about 16sq inches

Hi Topher,
Would appreciate learning about your method of applying the treatment. On what basis do you select patients for this treatment? Or do you treat everyone? What indications do you see it working best on and on which parts of the body? Which supplier do you use for the materials needed to prepare the blood? Thanks!

Can anyone from Europe share medium to long term expererience with this product?

You need some anaesthetic - we use topical fraxel gel or BLT and Penthrox if needed
You need to take blood into special test tubes - available from www.regenkit.com
Then centrifuge (you need one of them too) for 8 mins
draw off the plasma and inject through the dermis with 30g - 25g needles
Too easy.
Expecting results on necks, hands, around the eye region - antwhere where skin is crepy and needs thickening and tightening. have heard it works for acne scars (prick in with 25g needle) and am keen to try it on stretch marks

Hi Topher,

Great to hear from someone who's actually used the product.

I have to disagree with you though that this treatment is becoming big in Australia. Besides you, I've heard of only one practitioner, an asthetician, who's claiming good results, and I'm concerned her objectivity may be compromised by the fact that she's trialing it for Regen Labs.

I dont think regen labs are making this available to aestheticians - as far as i know its Dr supply only
I have already had to loan product to a local derm and a local cosmetic physician because they have run out off stock. I know most of the local docs involved in cosmetic work have been to training workshops. It was a big item in the Sydney CPSA/ACCS conference. So a lot off people are trying it at the moment as I am. DID - where are you based?

Apologies Topher, the practitioner who's promoting PRP in Sydney is a nurse, not an aesthetician. As far as I know she's run the Regen workshops and was also the demonstrator at the recent ACCS/CPSA conference. Whatever hype exists here seems to stem from this single source whose interests are possibly conflicted.

A literature search confirms applications in wound healing, but nothing much re rejuvenation. Seems like it's still at the trialling stage.

Hi guys,

I have been away from this site for months. Just happen to remember I was once actively involved in the discussion of Fractional CO2 laser.

I am practising in Hong Kong and I do go to Korea to see what the Korean drs are doing there. They seem to be upfront in terms of various applications, probably because they are less likely to be challenged there.

I am now in Soeul again.

In fact the Korean drs have been doing PRP for a couple of years at least. Now there are 10 comapnies making the PRP tubes. The drs here use PRP in combination of various Rx, including Fractional CO2, micro-needles, direct meso-injections, mix it with other things such as Hyaluronic acid, and also heat up the platlet poor portion into a gel and use it as filler either on its own or mix with HA. Appraently "plasma filler" is being done allover Korea.

However, this is still not as popular as the fat derived stem cells usage, but certainly much more suitable for drs who does do do any forms of liposuction in their office. Mind you the Korean drs do everything in their clinic which is equipped like a decent OT room with heauv investments. They do not go to private hospital here. They call their clinic a hospital!

Anyway, they seem to be very certain about the good effects, and I know of a few drs going around Asia to give semninars on this.

Dr stephen

Hi Shaharom,

I have just order a SmartXide from Matt. We have been doing some PRP in the office - too early to see results. Let me know how you go with the combination. Also how has stacking affected your parameters and results with the dot?

Totally agree - early trial stages and we are all waiting to see our results. I have had a few patients in after 1 treatment for their second go - and some not much difference but some very impressive results - and on hard areas to improve with anything else eg necks and fine smile / accordian / cheek lines. Seeing as we are recommending 3 monthly treatments and then wait 3 months for full collagenesis effect, and these first patients are 1 month after one treatmengt and seeing changes - I am very hopeful.

Hi Everybody

I am in Queensland

Just ordered a Smartxide from Matt as well; Have also done workshop for PRP here with Jeannie Devereaux (has since left to go to Uni) who represents AMSL -suppliers of the Regen tubes at A$100 each;

Would like to hear everybody else's experience with these two treatments as they appear to complement each other; I read in Net that PRP can be good for diffuse alopecia as well!!

Dr Stephen--are there big clinics in Korea or Japan(apparently they are very experienced too) where one can apply to go & learn more of what they do there?

I would VERY much like to know if anyone knows of an alternative supplier of PRP tubes - $100 a tube is too much! Keh - I am in Qld also. Getting some good early results on PRP on necks and faces
There was an article in a recent Hair Transplant Forum on PRP for hair regrowth but minimal study numbers. I am trying it out

I would also like to know if anyone knows of an alternative supplier of PRP tubes...

I m located in Europe and heard some stories about Regen Lab ( PRP ) . Many doctors are happy about it. They use it for many different indications : hair regrowth, to increase the lipe, smoothing the wrinkles, dark circles under the eyes. I don t many detalis about but most doctors who used it generalyare happy abou itt.

Hi guy,

Sorry kept forgetting to come up to the forum.

It is 3 .5 weeks since I got back from Korea, and my dr friend did 1. Plasma fillers on my NL fold, lower eyes areas. 2. PRP into the fillers. 3. Fractional CO2 laser. 4. Cryo-electroporation with thr remaining PRP.

Results: eyes bags better moderately. But is it due to the release of fibrosis with the cannula action? Not sure. Skin quality may be better but not convinced with a hugh difference for the discomfort I went throught for 2 -3 days after.

Alt PRP sources: many in Korea. My dr friend wants to sell me to use his stuff too ( i think he has some interest in it) It costs US 100 which is more expensive than the Regen at Aus 100.

I would like to have comment on the use on centrifuge. Simple one or large sophisticated one??

Hi guy,

Sorry kept forgetting to come up to the forum.

It is 3 .5 weeks since I got back from Korea, and my dr friend did 1. Plasma fillers on my NL fold, lower eyes areas. 2. PRP into the fillers. 3. Fractional CO2 laser. 4. Cryo-electroporation with thr remaining PRP.

Results: eyes bags better moderately. But is it due to the release of fibrosis with the cannula action? Not sure. Skin quality may be better but not convinced with a hugh difference for the discomfort I went throught for 2 -3 days after.

Alt PRP sources: many in Korea. My dr friend wants to sell me to use his stuff too ( i think he has some interest in it) It costs US 100 which is more expensive than the Regen at Aus 100.

I would like to have comment on the use on centrifuge. Simple one or large sophisticated one??

Simple centriguge - able to spin at about 3500 rpm. Should be around US$200

Topher,

If $ aus 100 is too much, then you can imagine how I feel when the agent (Neo Derm) told me this morning they are selling for HK 1400, which is about aus $ 222, here in Hong Kong. This is a rip off.

BTW, we are not just injecting PRP, right?? It is "activated" PRP, with an activator. Otherwise, we can just spin down the blood and get the PRP from a plain test tube, without buying these commercial kits.

So can we have some light on this "activating process" which is the soul of the kits, and what they are charging for.

Information anyone please?

hi fellas

have a look at this website.

http://www.bolandcell.co.za/COSMETIC-PRP-2010.html

this seems to be from a Prof Don Du Toit, who is amongst the authorities quoted in the PRP manual from the company. From this article it looks as though Prof Du Toit, seemongly once a big fan of PRP, has evidence of it being, let's say, not everything it is cracked up to be.

It's a big site, lots of detail on PRP, certainly doesn't read like a selling site.

Hmmmm

dear dr stephen

I'm no expert but from what I can gather there's nothing special in the tubes and the process aside from those designed to:

1) prevent premature clot formation: citrate, as is used in the preparation of packed cells for transfusion, and as is used in vacutainers for INR, APTT and D-Dimer testing (Douglass Hanly Moir), is prefered to EDTA. I don't think a plain test tube will do.

2) spin the blood in such a way as to ensure platelets are not prematurely damaged: the gel in the tube has something to do with this, as well as spinning at 3000 revs for 8 minutes (although other parameters are given as well)

3) remove the platelet-poor plasma: if this isn't done, you are not later injecting "platelet-rich plasma" (P-RP), you are injecting plain ol' plasma (POP)

4) add some calcium: this is the step that starts the cascade of release of the Magnificent Seven growth factors from the (now concentrated) platelets.

5) start squirting, man.

That's my grasp of it. Any advances, anyone?

Is that worth $100 a tube? Arguable.

As far as there being any other "activator", I didn't see anything more special than this is the literature from the company, and if there were something secret and special in the mix, it would get called a "drug" and you'd have to know a bit more about it before injecting it.

Would love to be corrected and enlightened if I am wrong

The test tubes are labelled THT - Thrombocyte Harvesting Tubes. The company goes to great lengths to explain that any old test tube will not do because 1 thrombocytes must be kept alive and 2 gel etc in tube must be fit for injection, ie ordinary path tubes may contain gels etc which may contaminate the plasma and be unsafe if reintroduced into the body
After centifuging the plasma is separated from the RBC's by the gel
I am still getting impresive results with my early forays into this treatment.
After my training from Regen lab I use all the plasma - why waste any? Better to inject 5ml of rich and poor plasma than 2.5 ml of rich plasma and miss the platelets in the poor plasma out completely.
I think the only activator is the Calcum Chloride added prior to injecting

Platelets from the blood bank are good for 5 days after donation. The platelet bag should be not refrigerated and should be kept on an agitator. If platelets can survive the Blood Bank for 5 days, and if we are, in preparing P-RP, using the platelets more or less immediately, ensuring platelet survival should be a matter of simply avoiding exposure to toxins, heat, trauma, etc, moreso than adding any sort of special elixer-of-youth-for-platelets.

Slow centrifuging would be key. Getting the sodium citrate concentration correct would be important as well.

As far as the centrality of the gel to the process is concerned, I'm old enough to remember the days before gel of any sort came in path tubes. Spin anticoagulated whole blood and the red cells separate out: gel or no gel. True, you would then need to pick up the tube carefully prior to pipetting off first the top supernatant platelet-poor plasma then the next layer supernatant platelet-rich plasma, because if you shake or invert the tube the red cells will mix in again, but, hey, that isn't rocket surgery.

The advantage of gel, per se, in a path tube is that it allows ease of handling once the tube has been spun, because the red cells don't then remix if you drop or invert the tube. That's all.

Regarding "why waste any?", the entire point, as far as I can see, of using P-RP is to create supraphysiological growth factor effects in the treatment area by injecting a plasma of supraphysiological platelet concentration. Marx, in his monographs, seems to make a big deal of achieving high platelet concentrations in the P-RP for this very reason. If plasma with a normal concentration of platelets will do the same thing, then the easier way to achieve extravasation of a patient's plasma into a target area would be to strike the target area with a baseball bat. Or, slightly more elegantly, venepuncture your patient and draw up some whole blood then reinject this blood into the target site. Admittedly you'd get red cells along with the plasma. Hematoma. But the platelets would be 100% fresh, viable, and would get activated by collagen strands, etc.

The clinical papers used to support the use of P-RP for cosmetic purposes all relate to using it hasten or enhance repair following surgery or laser treatments, etc, which is a totally different pathophysiological situation. They also relate to using supraphysiological concentrations of platelets in the plasma. Using plasma of normal platelet concentration removes the process yet one more step away from its medical literature underpinnings and is indistinguishable from creating an erythrocyte-less bruise - which is supposed to do........?

Has anyone read the Du Toit link in my first contribution? The one in which he (or at least his website) quotes a 12-month study demonstrating *no* enduring cosmetic improvements following P-RP? This, coming from a guy whose earlier and older writings were all in favour of P-RP?

Hmmmmmm..........

(PS. Someone is going to say that removing the red cells still concentrates the platelets 1.7 fold. The company literature makes the same claim. But this is misleading. Mature red cells are just big space-occupying bags of hemoglobin when it comes to plasma physiology at the molecular level. They don't participate. Arguing that taking the red cells out of blood will make the platelets more concentrated is like arguing that taking the holes out of Swiss cheese will make it taste stronger)

But I may be wrong.

Having said all that, the du Toit article, if in fact he wrote it, makes some very weird claims the other way. In particular, there is some outright scaremongering over a purported cancer risk, claimed to be linked to the IGF released by the platelets. That's nonsense, for so many reasons.

But it would be interesting to read the study on the recipients of P-RP 12 months down the track.

Having said all that, the du Toit article, if in fact he wrote it, makes some very weird claims the other way. In particular, there is some outright scaremongering over a purported cancer risk, claimed to be linked to the IGF released by the platelets. That's nonsense, for so many reasons.

But it would be interesting to read the study on the recipients of P-RP 12 months down the track.

Response, anyone?

Or am I, in fact, on the right track?

All I can say is that i am consistently seeing convincing improvement in fine lines, crepey skin, skin texture and sometimes a little skin tightening 1 month after 1 single PRP treatment as i perfrom them. Patients are happily proceeding with further treatment because they see the results themselves. Especially getting results on areas like neck skin which is almost impossible to achieve with any other modality that I know off.

I do not doubt that the process of injecting P-RP may lead to a month or two of induration and perhaps fibrosis. We see the same following liposuction. But after another month or two following liposuction all that goes.

The question is: for how long, and to what extent, is P-RP-treated skin going to appear different to non-P-RP-treated skin? Does a difference seen at one or two months imply such a difference will still be evident at say 6 or 12 months? Does the application of P-RP set the treated skin off on a new trajectory, or is it a mere ephemeral perturbation to the ageing process? I haven't yet seen answers to these concerns, but I know the history of cosmetic medicine is littered with treatment modalities that were impressive in the short term and useless in the middle to long term. I also know that we often see new modalities sold on the basis of a superficially-plausible basic biology argument that does not bear closer scrutiny, and that in such a case there is often a distinct lack of even medium-term trials.

I would love for P-RP to be different.

mahony

I love your sense of humour and quite agree to many points you pointed out.

Treatment modalities impressive in the short term but pretty useless in the medium and long term - I immediately have fraxel and thermage in mind.

Back to PRP, thanks so much for your insights. So we are talking about 2 things gere:
1. The preparation kit - is it anything special?
2. The PRP - does it really work? If yes, Short term? long term?

Since my last entry I have searched a little but more and likewise, I cannot convice myself why I have to use a "commercial kit" selling at a lot of money. Ok, not plain tube. What about we add in a few drops of anti-coagulant, and at the end a few drops of Cacium chloride? I believe it will work similarly.

Remember I had the PRP and platelet poor plasma gel filler done on MY own face back in June? I have to say I am kind of agreeing to you. My eyebags were a bit smaller, noticeable to some friends. Skin is a bit smoother. All is not a "wow" though, no wonders done. Now over 2 months gone, I need to look for the supposed improvement in the mirror.

Anyway, stupid me. I have just ( yesterday) invested US 10000 for a "sophiticated centrifuge" + 100 set of PRP kits from "the best selling PRP company in Korea" which accounts for 70% of the PRP kits sold to doctors in Korea. Reasons why i am doing this?

1. Something new to my clinic. Bored may be.
2. US 10000 to start is still a lot less than any other "machines" costs
3. To prepare the 'Kit" in a DIY way costs a lot of effort. Forget it, you need to let other people to earn a living too, to boost the economy, so to say
4. Drs are chaging a lot more here in HK, something like Us 2000 per treatment! So I can get my money back after 5 patients!

I have compared the kits from the Regen, and as I now believe there is nothing really special about them, except they help the seperation process, I am happy enough with the Korean kit, which I can harvest more volume in 1 go, and a bit cheaper (US 80 compare to US 180). Well, the company says that their kits make PRP with more platelet!

Simply describing the kit: a cone shape tube inside a round tube, so the centrifuged out RBC get out of the cone into the round tube and will not go back in. The 2 supernatant layers: Platelet rich and platelet poor plasma stay inside the cone. You can adjust the content up and down by twisting the bottom cover of the tube. At least I feel that I am paying for some more thought in the design than the Regen which are just simple test tube with a gel!

dr stephen

Just want to say that I am not jumping into this PRP thing. I have known about this for 3 years + and on and off researched about it. Only until now when it is hitting the market at last that I decide to go in.

Hi Dr Stephen,
is it possible for me to visit you in HK to see your practice?
I'm visiting HK on the 8th -11th September for attachment with Dr William FUng.
But if its a hassle , its ok...
I have few regenLab kit given free to me when I bought the SmartXide , still hasnt use it
yes they are expensive , around USD180 per set.
I saw this korean PRP kit in one of the seminar I went, when I ask the distributor (RegenLab) regarding
the Korean kit , they claim regenlab kit collecting a higher % of Platelet compare to others...
and they claim that to have a significant results , the percentage of PRP must be to a certain %...

I wont mind you visiting but just that I am still setting this PRP things up. You can see the centrifuge that I use and the kit. Well hell, regarding the Platelet %, we wont get the truth unless we do a comparative test for all of them. I guess we can set a standard preparation procedure and send the samples to a Haematology lad for the %s!

I am off to Korea again from 4 - 7th September for a conference "minimally invasive plastic surgery". I hope to see what other Korean drs are saying about their practice, as well as to see some reps in the exhibition booths. Hopefully will bring something new back to my clinic.

thats great dr stephen
just give me your address...
and I might drop by...
I will be in HK 8-11 sept
regarding the % , i have read a studies done by the regenlab regarding which kit harvest the highest PRP
RegenLab is in the top 3..
but still not the best..

I suppose it would have occurred to everyone that harvesting the highest concentration of platelets would be dependent entirely on the parameters chosen for the centrifugation and the proportion of platelet-poor plasma thence removed, rather than anything intrinsic to the "kit".

Generally speaking, slower centrifugation gives you a finer gradation of particle size & better separation of the various sedimentary layers, doesn't it? So you will then more likely get a nice neat compacted layer of platelets above your gel.

Then, of course, the degree of concentration of platelets in your platelet rich plasma is inversely proportional to the amount of platelet-poor plasma you throw away. So, if you've got 5ml of plasma and you throw away 2.5ml of plasma you've deemed platelet-poor (assuming for argument's sake perfect centrifugation), you've doubled the concentration of platelets in the remaining 2.5ml plasma. And if you throw away 4ml P-PP, you're left with 1ml of 5X concentration P-RP. Etc.

ooooooooooooooooooooooooooooo

Interestingly, in email exchanges I have recently had with the ReGenLab company I have communicated with their CEO, Antoine Turzi, about whom the following is said on the BioPortFolio website

"ReGenLab has been founded in 2003. The founder, Antoine Turzi law graduate, has solid entrepreneur experience in medical and non-medical field and received granted two patents used in ReGenLab. The company currently assembles expertise in several medical fields e.g.: regenerative medicine, chronic wound care, and possesses Life Science Industry experience of 25 years gathered in international environment."

Anyhow, Dr?Mr? Turzi seemed to say in his email that concentrating the platelets was now an "old concept".

I quote:

"With the RegenKit yolu have a full plasma in physiologic concentration, which is consider today the best cell concentration for rejuvenation, because the old concept of high concentration can have inhibitory effect since the cell receptors are busy, and do their work." personal communication 19/8/09

As one would, I have sought further clarification about this but have had no further response.

Strange, n'est-ce pas?

Cheers

Dr Shah,

I just got equipped with the "most popular" Korean PRP kit. You can find me at 20/F, Kailey Tower, Stranley St. Central, HK. Call 2890-8020, if you want to discuss anything.

Mahony,

I perfectly agree with what you said about: it is just simply how well you can retrieve the "platelet rich portion" rather than anything intrinsic of the tubes.

After asking more and more, it is clear to me what they are claiming : it is how well the tube's or the gel's design that "help you to retrieve the platlet rich portion, with the least difficulty, and the most consistency" for the average doctor.

I still believe that even with simple tubes, we can do the same PRP. But then again I am not sure if I can repeat and repeat again, with a similar concentration. So I bent my arms to accept that the tubes are just a tool to help me do it more easily, and "perhaps" with more consistency. And so I paid the money for the PRP set.

Ah, 1 more thing. I just been to the 1st internation conference of mini-invasive plastic surgery in Seoul, and I am led to believe that you need a "scaffolding" for the PRP to work, otrherwise the rejuvenation result is pretty minimal. The scalffoding can be a fat graft, a emusified fat gel, plasma gel, or HA gel. Now the Korean doctor I know is testing on giving GCSF-1 to a patient for 4 days to pump out the bone marrow stem cells, and then collect the blood for centrigugation, and collect the "stem cells buffy coat". Well again sound innovative to me, though I am not sure it will work. Thought stimulating though.

dr stephen

Hi Dr Stephen,
I just arrived fron Guangdong this evening and currently staying in the regal hotel, I will google your address and hopefully I can visit you . Hong Kong , Korea , Japan are very much advanced in aesthetic medicine relatively compare to us malaysia.

Hope to learn from you

Hi Mahony,

A kindred sceptic!! Advocates of PRP have surely been at it for longer than 6 months already. Have you seen any medium term results first hand?

yes - lots. In fact I would say 90% getting results after 1-3 treatmnts in my experience

Has PRP aggravate risk of cancer?

Has PRP aggravate risk of cancer?

Hi Topher

Do you have any before and afters that you could post?

Dr Shah,

I just got equipped with the "most popular" Korean PRP kit. You can find me at 20/F, Kailey Tower, Stranley St. Central, HK. Call 2890-8020, if you want to discuss anything.

Mahony,

I perfectly agree with what you said about: it is just simply how well you can retrieve the "platelet rich portion" rather than anything intrinsic of the tubes.

After asking more and more, it is clear to me what they are claiming : it is how well the tube's or the gel's design that "help you to retrieve the platlet rich portion, with the least difficulty, and the most consistency" for the average doctor.

I still believe that even with simple tubes, we can do the same PRP. But then again I am not sure if I can repeat and repeat again, with a similar concentration. So I bent my arms to accept that the tubes are just a tool to help me do it more easily, and "perhaps" with more consistency. And so I paid the money for the PRP set.

Ah, 1 more thing. I just been to the 1st internation conference of mini-invasive plastic surgery in Seoul, and I am led to believe that you need a "scaffolding" for the PRP to work, otrherwise the rejuvenation result is pretty minimal. The scalffoding can be a fat graft, a emusified fat gel, plasma gel, or HA gel. Now the Korean doctor I know is testing on giving GCSF-1 to a patient for 4 days to pump out the bone marrow stem cells, and then collect the blood for centrigugation, and collect the "stem cells buffy coat". Well again sound innovative to me, though I am not sure it will work. Thought stimulating though.

dr stephen

Cancer researchers have known for years that any time you increase the number of cells dividing and growing, you increase the chances of cancer especially if you add sunlight to the mix. A wound/scab... on the face or arm has a greater chance of becoming cancerous esp. if exposed to sunlight. The risk is decreased if the wound is covered with a bandage so that it does not receive sunlight.
PRP adds an increased number of cells to an area, thus increasing the chances some could turn cancerous. Laser treatments cause wounds in the skin which then regenerate (dividing and growing) increasing the chances of cancer. Heck Retin-A increases cell growth and turnover and probably has the same results.
Having your patients avoid sunlight and tanning beds during the healing phase would drastically decrease the chances of cancer even more than the normal sun protection procedures that should be followed for everyone.

I forgot to add that while cancer might be possible, I would think it would be unlikely from these procedures esp. if they stay out of the sun while healing.

LMBB

Most of the contributors to this particular forum have medical degrees and can put these discussions in context.

I always respect an enquiring mind: with your current level of knowledge of this field, you need to be asking a lot more questions rather that delivering your opinions.

Keep enquiring.

"Cancer researchers" differentiate between mitogenesis and mutagenesis. You should, too. Cell division, generally, is a good thing: you'd be dead in days without it. Bandages have a number of roles: but "sun protection" would not rate in the top ten. PRP takes cells from one part of the body and re-delivers them to another - the net effect on carcinogenesis is exactly zero. laser treatments do not cause cancer unless they use a mutagenic wavelength: and no such laser is used in cosmetic dermatology (psoriasis and vitiligo aside). Retin-A is a free-radical scavenger/antioxidant - reduces cancer risk.

If you want to ask a question you might ask, for example: "PRP causes nothing but an erythrocyte-less bruise. Is there any evidence that such lesions cause cancer?" and the various doctors contributing to this forum would answer "No. We know of no evidence that repetitive bruising in a given location causes cancer. We are aware, as doctors, of Marjolin's ulcer, which is an SCC arising in an area of generally repeated trauma, but this is ectodermal, and most bruises are mesodermal, which is far less likely to give rise to cancer. For example, IV drug users, traumatising their cubital fossas several times per day, day after day, rarely if ever get cancers in their cubital fossas."

Keep asking. Keep learning. That's the way.