I read with great interest the article by Kim et al. This article was published in July of 2013 and concerns the effect of platelet-rich plasma on flap survival.1 The authors nicely showed that platelet-rich plasma can improve flap survival area. I would like to complete the discussion of Kim and colleagues by introducing a major complementary route through which platelet-rich plasma could reduce flap necrosis.
There is a growing body of evidence that a significant portion of flap necrosis is triggered by a sequence of events associated with reperfusion of ischemic tissues, termed “reperfusion injury.”2 The major explanation for reperfusion phenomena is up-regulation of surface adhesion molecules on the vascular endothelium with subsequent adherence and accumulation of polymorphonuclear leukocytes within the vessel lumen. Adherence of polymorphonuclear leukocytes is mediated predominantly by beta-2 integrins (CD11/CD18) on their surface through activation of the NF-kappaB/RANKL pathway.3 Osteoprotegerin, which is a decoy receptor of RANKL, can block the NF-kappaB/RANKL pathway.4
Platelet-rich plasma, which is also called platelet gel, effectively stimulates osteoprotegerin production, leading to significant block of the beta-2 integrin/NFkappaB/RANKL pathway, which subsequently leads to decreased polymorphonuclear leukocyte aggregation and reperfusion injury.5 Therefore, this important mechanism should be borne in mind as the major complementary mechanism for platelet-rich plasma–reduced flap necrosis.
The author has no financial interest to declare in relation to the content of this communication.
Hamid Namazi, M.D.
Department of Orthopedic Surgery
Shiraz University of Medical Sciences
Shiraz, Islamic Republic of Iran
1. Kim HY, Park JH, Han YS, Kim H. The effect of platelet-rich plasma on flap survival in random extension of an axial pattern flap in rabbits. Plast Reconstr Surg. 2013;132:85–92
2. Freitas FA, Piccinato CE, Cherri J, Marchesan WG. Effects of pentoxyfilline and heparin on reperfusion injury island skin flaps in rats exposed to tobacco. J Surg Res. 2010;164:139–145
3. Kim CH, Lee KH, Lee CT, et al. Aggregation of beta2 integrins activates human neutrophils through the IkappaB/NF-kappaB pathway. J Leukoc Biol. 2004;75:286–292
4. Nelson CA, Warren JT, Wang MW, Teitelbaum SL, Fremont DH. RANKL employs distinct binding modes to engage RANK and the osteoprotegerin decoy receptor. Structure. 2012;20:1971–1982
5. Ogino Y, Ayukawa Y, Kukita T, Atsuta I, Koyano K. Platelet-rich plasma suppresses osteoclastogenesis by promoting the secretion of osteoprotegerin. J Periodontal Res. 2009;44:217–224
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