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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 240-243

The effect of locally infiltrated platelet-rich plasma on survival of skin flaps in degloving injuries


Department of Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission10-Dec-2020
Date of Decision31-Jan-2021
Date of Acceptance10-Mar-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Aditya Pundkar
Department of Orthopaedics, J N Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_439_20

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  Abstract 


Background: Partial- or full-thickness necrosis is normally encountered complication postoperatively in skin flap patients. The chief causes of necrosis are reduced arterial flow, venous insufficiency, or both. Particularly, necrosis of the skin flap occurs in the more distal portion of the flap, if arterial or venous flux insufficient. The other factors owing to the necrosis of skin flap are qualitative and quantitative deficiency of local growth factors (GFs) and lack of regulation of various GFs. Platelet-rich plasma (PRP) is the concentrate of plasma prepared by serial centrifugation and contains high concentrates of platelets. It is rich in various GFs which are essential for wound healing. Materials and Methods: Six patients were included in the study. All the patients had traumatic degloving injuries of lower limbs. After primary cleaning and closure of the flaps, from postoperative day 1, all the flaps were infiltrated with autologous PRP infiltration according to STARS therapy till the wounds healed. Results and Observations: All the wounds healed completely with PRP. PRP sessions required ranged from 4 to 7 with an average of 5.4. There was no need of any additional procedure for wound healing such as serial debridements and skin grafting in any of the patients. Two patients required additional procedures for associated fractures which involved K-wire removal and amputation of the fifth toe. Complications such as infection, abscess, or sinus formation were not seen in any of the patients. After suture removal, the mean ± 2 standard deviation total wound area was 31.5 ± 17.6 cm2, mean necrotic area was 7.75 ± 5 cm2, and mean surviving area was 23.75 ± 13.8 cm2. The mean percentage survival of the flaps was 75.119%. This value is comparable with other studies. Conclusion: In our study, it was found that local autologous PRP infiltration in the skin flap of degloving wounds according to the STARS therapy increases the chances of survival of flap.

Keywords: Platelet rich plasma, skin flap necrosis, necrosis


How to cite this article:
Pundkar A, Shrivastav S, Date S. The effect of locally infiltrated platelet-rich plasma on survival of skin flaps in degloving injuries. J Datta Meghe Inst Med Sci Univ 2021;16:240-3

How to cite this URL:
Pundkar A, Shrivastav S, Date S. The effect of locally infiltrated platelet-rich plasma on survival of skin flaps in degloving injuries. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Dec 4];16:240-3. Available from: http://www.journaldmims.com/text.asp?2021/16/2/240/328474




  Introduction Top


Skin flaps are frequently used in plastic surgery, general surgery, or orthopedics to repair any defects that occur after trauma (compound fractures or degloving injuries), congenital abnormalities, or after excision of swelling. Partial- or full-thickness necrosis is normally encountered complication postoperatively. The chief causes of necrosis are reduced arterial flow, venous insufficiency, or both. Particularly, necrosis of the skin flap occurs in the more distal portion of the flap, if arterial or venous flux in insufficient.[1],[2],[3] The other factors owing to the necrosis of skin flap are qualitative and quantitative deficiency of local growth factors (GFs) and lack of regulation of various GFs. Among the many factors that affect wound healing, cytokines and GFs are known to promote the healing process and to accelerate the new vessel formation. These GFs include transforming growth factor (TGF), fibroblast growth factor (FGF), and vascular endothelial cell growth factor (VEGF).[4],[5] Over the last three decades, there have been a lot of studies carried out to prevent necrosis and increase flap viability. Various pharmacological agents have been used experimentally including vasodilators, prostaglandin inhibitors, anticoagulants, and free radical scavengers. However, a clinically significant approach is yet to be established.[6],[7]

Platelet-rich plasma (PRP) is the concentrate of plasma prepared by serial centrifugation and contains high concentrates of platelets. It is prepared by sequestering and concentrating platelets by gradient density centrifugation. There are various granules in platelets, namely alpha, beta, and lambda. Among these, alpha-granules contain various GFs which promote wound healing as well as new vessel formation in the skin flap. The list of GFs includes platelet-derived growth factor, epidermal growth factor, FGF, VEGF, keratinocyte growth factor, TGF-β, and insulin-like growth factor. All these factors lead to stimulation of mesenchymal and epithelial cell migration and division and thus lead to increased collagen and matrix synthesis.[8],[9],[10]

PRP has been suggested for enhancing the efficiency of bone regeneration and soft-tissue reconstruction. It has been demonstrated that PRP is a viable alternative treatment for clinical applications and has potential benefits for use in chronic wounds. The controlled release of PRP GFs has shown a positive stimulatory effect on chronic pressure ulcer healing rate. PRP is used clinically for bone and wound healing, oral and maxillofacial surgery, dental surgery, and plastic surgery. However, there are not many studies that support the use of PRP for survival of skin flap in degloving injuries. Hence, we have conducted this study to demonstrate the effect of PRP on survival of skin graft in degloving injuries as well as on new vessel formation.[11],[12],[13]


  Materials and Methods Top


This study was performed at Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha. The study was performed on six patients coming to the emergency department with lacerated wounds over feet, ankle, or distal leg as a result of trauma. All the patients were taken to emergency operation theater, and after debridement and cleaning of the wound, local skin flapping was done to cover the area of wound as much as possible. From the 1st postoperative day, PRP infiltration was started in the skin flaps according to the STARS therapy. The technical details are as follows.

Preparation of platelet-rich plasma

The method uses freshly drawn, 20 ml, venous autologous blood. This blood is then transferred to 4 ethylenediaminetetraacetic acid bulbs so that each contains 5 ml of blood. Blood is then centrifuged at 2000 revolutions per min for 10 min. This will divide the venous blood into two parts: the upper part contains plasma and the lower part contains red blood cells. The upper part of the test tube, i.e. plasma, is collected in separate test tube. This plasma is then again centrifuged at 1200 revolutions per min for 10 min. By this second centrifugation, plasma gets divided into two parts: the upper part called as buffy coat and the lower part which is rich in platelets. From 20 ml of venous blood, approximately 2–4 ml of PRP is extracted. This PRP is then used for local infiltration along the margins of skin flap in degloving injuries.

”STARS” therapy protocol

The autologous PRP which is extracted by the abovementioned method is then taken into a 5-ml syringe with a 22G needle and then infiltrated along the margins of the skin flap at rate of 0.2 ml/cm until the whole length of the flap gets covered. This process of preparation of PRP and local infiltration along margins of skin flap is then repeated every 4th day till the wound gets healed completely. Dressing of the wound is done every alternate day with saline or daily if needed. No other surgical procedures such as serial debridement of the wound or local skin grafting are performed. No additional medications like antimicrobials were prescribed to the patients in our study. Analgesics were prescribed if needed. Only nutritional supplements such as multivitamins and Vitamin C were prescribed to the patient once and twice daily, respectively.[14]

PRP infiltration was done in skin flaps of all the patients every 4th day till the wound healed. Evaluation of the survival of flap was done on the basis of visual inspection and palpation during every dressing. Dressing was done every day or every alternate day depending on the wound. Suture removal was done on the 11th day postoperatively. Calculation of the viable part of the flap was done after suture removal. The areas of the flap that were darker in color as compared to normal skin, woody hard, showing loss of sensations (pain and touch), or covered with black eschar were considered as dead area. Furthermore, the area of the flap which lacked active bleeding after pricking with needle was considered as dead. On day 11 postoperatively, the dimensions (calculated by multiplying maximum length to width) of total and dead areas of each flap were measured and the surviving area (calculated by subtracting dimensions of dead area from total area) was calculated in cm2. The percentage of flap survival was then calculated (by dividing the surviving area by the total flap area and multiplying it with 100).[15],[16]


  Results and Observations Top


The mean age of the patients in our study was 34.4 years. All the six patients were male. All the patients had wounds secondary to trauma (road traffic accidents) involving foot, ankle, or lower leg. Three out of six patients had associated fractures which were treated with suitable measures. Cleaning and debridement of wound along with suturing of flap was done on the 1st day of injury in all six patients. Appropriate antibiotics were administered intraoperatively. The mean duration between presentation and intervention was 6.2 h. All the six patients were started with intradermal autologous PRP infiltration along the edge of the skin flap on the 1st postoperative day. All the wounds healed completely with PRP. PRP sessions required ranged from 4 to 7 with average of 5.4. There was no need of any additional procedure for wound healing like serial debridements and skin grafting in any of the patients. Two patients required additional procedures for associated fractures which involved K-wire removal and amputation of the fifth toe. Complications such as infection, abscess, or sinus formation were not seen in any of the patients. After suture removal, the mean ± 2 standard deviation total wound area was 31.5 ± 17.6 cm2, mean necrotic area was 7.75 ± 5 cm2, and mean surviving area was 23.75 ± 13.8 cm2. The mean percentage survival of the flaps was 75.119%. This value is comparable with other studies [Figure 1] and [Figure 2].
Figure 1: (a) Degloving injury over the right foot. Image was taken immediately on presenting to the hospital. (b) Sutured lacerated wound over the medial aspect of the right foot. Image was taken immediately after the cleaning and suturing of the skin flap. (c) Condition of skin flap after first platelet-rich plasma session. (d) Condition of flap after suture removal and third platelet-rich plasma session. (e) Final wound condition after complete healing. A patient required five platelet-rich plasma sessions for complete healing

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Figure 2: Diagrammatic representation of method of calculating total flap area, dead flap area, and surviving flap area. Black line denotes total flap area, red line denotes dead flap area, and surviving flap area was calculated by subtracting dead area from total area. Area was calculated by multiplying maximum dimensions (length and breadth) of the particular area

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  Discussion Top


Flap necrosis is a serious complication in general surgery, plastic surgery, and orthopedics practice. The major factors responsible for flap necrosis are reduced blood supply (arterial and venous) resulting from damage to the subdermal plexus during surgery, thrombosis or tension on the flap edges, and ischemia-reperfusion injury. It also occurs as a result of qualitative and quantitative reduction of various GFs as well as faulty regulation of various GFs. Body's response to trauma (open wounds with damage to blood vessels) is aggregation of platelets. These platelets upon their activation release a large amount of GFs and various cytokines which play an important role in wound healing as well as new vessel formation. As more and more platelets get aggregated at the wound site, the amount of GFs and cytokines also increases, therefore, an increased number of platelets at injury site or surrounding the skin flap lead to better wound healing and also to better new vessel formation in the flap. This is the basis of usage of PRP in survival of skin flaps in degloving injuries.[17] Routinely in practice, activated PRP (activation done by adding thrombin or calcium chloride) is being used for various practices. In our study, we have been used inactivated PRP, but we found good results. This shows that inactivated PRP can also be used with similar efficacy. Various animal studies have been conducted to show the effect of PRP on skin flap survival, but there have been very few human studies. In our study, we have tried to find out the effect of local infiltration of PRP on survival of skin flap. PRP helps in wound healing and in new vessel formation in the skin flap due to the presence of various GFs present in the alpha-granules of the platelets. In our study, we found that local PRP infiltration leads to increased chances of skin flap survival.


  Conclusion Top


In our study, it was found that local autologous PRP infiltration in the skin flap of degloving wounds according to the STARS therapy increases the chances of survival of flap. Furthermore, PRP can enhance the new vessel formation in the skin flap. PRP has greater benefits in new soft-tissue generation. The effectiveness of local infiltration of autologous PRP in skin flap is satisfactory. The mechanism by which the PRP promotes skin flap survival includes various GFs, present in the alpha-granules of the platelets. The GFs in PRP may enhance the nutrition and survival of the skin flap. PRP to some extent also has some antimicrobial and anti-inflammatory properties. These properties also aid in wound healing. Hence, PRP can be used as a new clinical modality for improving skin flap survival rates in degloving injuries.


  Acknowledgment Top


We would like to thank the Department of Orthopaedics, Datta Meghe Institute of Medical Sciences, Wardha.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Simman R, Craft C, McKinney B. Improved survival of ischemic random skin flaps through the use of bone marrow nonhematopoietic stem cells and angiogenic growth factors. Ann Plast Surg 2005;54:546-52.  Back to cited text no. 1
    
2.
Lu F, Mizuno H, Uysal CA, Cai X, Ogawa R, Hyakusoku H. Improved viability of random pattern skin flaps through the use of adipose-derived stem cells. Plast Reconstr Surg 2008;121:50-8.  Back to cited text no. 2
    
3.
Padubidri A, Browne JE. Effect of vascular endothelial growth factor (VEGF) on survival of random extension of axial pattern skin flaps in the rat. Ann Plast Surg 1996;37:604-11.  Back to cited text no. 3
    
4.
Kryger Z, Dogan T, Zhang F, Komorowska-Timek E, Shi DY, Cheng C, et al. Effects of VEGF administration following ischemia on survival of the gracilis muscle flap in the rat. Ann Plast Surg 1999;43:172-8.  Back to cited text no. 4
    
5.
Pierce GF, Tarpley JE, Yanagihara D, Mustoe T, Fox GM, Thomason A. Platelet-derived growth factor (BB homodimer), transforming growth factor-beta 1, and basic fibroblast growth factor in dermal wound healing. Neovessel and matrix formation and cessation of repair. Am J Pathol 1992;140:1375.  Back to cited text no. 5
    
6.
de Lima Silva JJ, Guimaraes SB, Da Silveira ER, de Vasconcelos PR, Lima GG, Torres SM, et al. Effects of Copaifera langsdorffii Desf. On ischemia-reperfusion of randomized skin flaps in rats. Aesth Plast Surg 2009;33:104-9.  Back to cited text no. 6
    
7.
van den Heuvel MG, Buurman WA, Bast A, van der Hulst RR. Ischaemia–reperfusion injury in flap surgery. J Plast Reconstr Aesthet Surg 2009;62:721-6.  Back to cited text no. 7
    
8.
Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte-and platelet-rich fibrin (L-PRF). Trends Biotechnol 2009;27:158-67.  Back to cited text no. 8
    
9.
Takikawa M, Sumi Y, Ishihara M, Kishimoto S, Nakamura S, Yanagibayashi S, et al. PRP and F/P MPs improved survival of dorsal paired pedicle skin flaps in rats. J Surg Res 2011;170:e189-96.  Back to cited text no. 9
    
10.
Schnabel LV, Mohammed HO, Miller BJ, McDermott WG, Jacobson MS, Santangelo KS, et al. Platelet rich plasma (PRP) enhances anabolic gene expression patterns in flexor digitorum superficialis tendons. J Orthop Res 2007;25:230-40.  Back to cited text no. 10
    
11.
Kim SJ, Kim SY, Kwon CH, Kim YK. Differential effect of FGF and PDGF on cell proliferation and migration in osteoblastic cells. Growth Factors 2007;25:77-86.  Back to cited text no. 11
    
12.
Sun W, Lin H, Xie H, Chen B, Zhao W, Han Q, et al. Collagen membranes loaded with collagen-binding human PDGF-BB accelerate wound healing in a rabbit dermal ischemic ulcer model. Growth Factors 2007;25:309-18.  Back to cited text no. 12
    
13.
Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: Implications for wound healing. Plast Reconstr Surg 2004;114:1502-8.  Back to cited text no. 13
    
14.
Shrivastava S, Singh PK, Taywade S. STARS therapy: “Sandeep's technique for assisted regeneration of skin.” J Orthop Allied Sci 2016;4:5.  Back to cited text no. 14
    
15.
Zhang F, Waller W, Lineaweaver WC. Growth factors and flap survival. Microsurgery 2004;24:162-7.  Back to cited text no. 15
    
16.
Alsousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery: A review of the literature. J Bone Joint Surg Br 2009;91:987-96.  Back to cited text no. 16
    
17.
Cole BJ, Seroyer ST, Filardo G, Bajaj S, Fortier LA. Platelet-rich plasma: Where are we now and where are we going? Sports Health 2010;2:203-10.  Back to cited text no. 17
    


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