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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e31828278f5
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Regenerative Surgery for the Definitive Repair of Chronic Ulcers: A Series of 34 Cases Treated with Platelet-Derived Growth Factors

Spagnolo, Francesco M.D.; Trapasso, Maria M.D.; Monteghirfo, Stefano; Barla, Annalisa; Scala, Marco M.D.

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Department of Plastic and Reconstructive Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale Per La Ricerca Sul Cancro (Spagnolo, Trapasso, Monteghirfo)

Dipartimento di Informatica, Bioingegneria, Robotica, e Ingegneria dei Sistemi, University of Genova (Barla)

Department of Surgical Oncology, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale Per La Ricerca Sul Cancro, Genova, Italy (Scala)

Correspondence to Dr. Spagnolo, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale Per La Ricerca Sul Cancro, Largo R. Benzi, 10, 16132, Genova, Italy francesco.spagnolo85@gmail.com

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Sir:

Regenerative surgery is based on the use of stem cells and/or platelet-derived growth factors, which induce stem cell migration to the damaged tissues, stimulating their proliferation and eventually resulting in tissue repair. Platelet gel is a hemocomponent containing numerous growth factors that are potentially useful for tissue repair.1 Platelet gel is used in oral bone implants2 and in combined soft- and bony-tissue reconstruction in facial plastic surgery3; in tendon and muscle repair4; and in the treatment of difficult wounds, ulcers, and injuries.5,6

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Thirty-four patients, aged 25 to 88 years, with chronic nonhealing ulcers were treated consecutively with platelet gel. Patient characteristics are listed in Table 1. Standard procedures (e.g., skin grafts or flaps) had already been performed to treat the ulcers, but failed.

Table 1
Table 1
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Platelet concentrate, cryoprecipitate, and thrombin were obtained from 450 ml of whole blood. Platelet gel was prepared by adding 1 cm3 of thrombin and then 1 cm3 of calcium gluconate for every 10 ml of platelet concentrate/cryoprecipitate solution. After proper wound bed preparation, platelet gel was layered on the lesion and covered by a patch loaded with platelet-derived growth factors.

The ulcers were located in the sacral/ischial region (n = 11), lower limbs (n = 12), feet (n = 7), and abdominal wall (n = 4); their cause was heterogeneous (14 pressure, seven venous, seven postoperative, and six posttraumatic). All ulcers were stage III, except for four stage IV ulcers (according to the National Pressure Ulcer Advisory Panel classification). All treatments involved the use of autologous (n = 22) or homologous (n = 12) platelet gel.

The average and median size of the lesions was 18 and 12 cm2, respectively (range, 1.5 to 99 cm2). The lesions had been present for a minimum of 6 to a maximum of 96 months, with an average of 18 months and a median of 8 months. Complete healing of all ulcers occurred in 10 to 240 days after a variable number of platelet gel applications (range, one to six). No complications related to the procedure were observed. No sign of recurrence was observed at last follow-up visit (minimum follow-up, 2 years). One case is summarized in Figure 1.

Fig. 1
Fig. 1
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Our study showed that the use of platelet-derived growth factors for the treatment of chronic, nonhealing ulcers is feasible and safe. Our study was not randomized to current best practice approach; only patients who had failed previous standard treatment were considered for the experimental procedure.

Some important findings emerged: time of healing was homogeneous with respect to the four types of ulcers considered; and no significant statistical correlation existed between time from diagnosis and time of healing, whereas ulcer size and time of healing were significantly correlated. These findings suggest that our procedure was limited by neither the type nor the longer duration of the wound, but only by its size. However, over a longer period, the largest ulcers also finally healed. The simplicity and cost-effectiveness of the operation and the minimal postoperative disability with complete wound healing suggest that this approach may represent an alternative to current surgical techniques for the treatment of chronic ulcers.

Thirty-four patients (aged 25 to 88 years) with chronic nonhealing ulcers (14 pressure, seven venous, seven postoperative, and six posttraumatic ulcers) were treated consecutively with autologous (n = 22) or homologous (n = 12) platelet gel. All patients suffered from the ulcer for at least 6 months (range, 6 to 96 months). Complete healing of all ulcers was obtained in 10 to 240 days after a variable number of platelet gel applications (range, one to six). As expected, a significant correlation between time of healing and ulcer size existed. Time of healing was homogeneous with respect to the four types of ulcers considered and did not depend on time from diagnosis. Definitive repair was obtained for all ulcers, suggesting that this new approach may represent a useful alternative to current techniques for the treatment of chronic ulcers.

Francesco Spagnolo, M.D.

Maria Trapasso, M.D.

Stefano Monteghirfo

Department of Plastic and Reconstructive Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale Per La Ricerca Sul Cancro

Annalisa Barla

Dipartimento di Informatica, Bioingegneria, Robotica, e Ingegneria dei Sistemi, University of Genova

Marco Scala, M.D.

Department of Surgical Oncology, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale Per La Ricerca Sul Cancro, Genova, Italy

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DISCLOSURE

The authors have no financial interest in any of the products or devices mentioned in this article. No external funding was received.

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REFERENCES

1. Jurk H, Kehrel BE. Platelets: Physiology and biochemistry. Semin Thromb Hemost. 2005;31:381–392.

2. Anitua E. Plasma rich in growth factors: Preliminary results of use in the preparation of future sites for implants. Int J Oral Maxillofac Implants 1999;14:529–535.

3. Bhanot S, Alex JC. Current applications of platelet gels in facial plastic surgery. Facial Plast Surg. 2002;18:27–33.

4. Del Buono A, Papalia R, Denaro V, Maccauro G, Maffulli N. Platelet rich plasma and tendinopathy: State of the art. Int J Immunopathol Pharmacol. 2011;24(Suppl 2):79–83.

5. Rozman P, Bolta Z. Use of platelet growth factors in treating wounds and soft-tissue injuries. Acta Dermatovenerol Alp Panonica Adriat. 2007;16:156–165.

6. Scala M, Spagnolo F, Strada P, Santi P. Regenerative surgery for the definitive surgical repair of enterocutaneous fistula. Plast Reconstr Surg. 2012;129:391e–392e.

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