1Junior Resident, Department of Surgery, Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER), Pondicherry, India
2MCh, DNB, MNAMS, FRCS (Edin), DSc, PhD(Plastic Surgery), Professor & Registrar (Academic),Head of IT Wing and Telemedicine, Department of Plastic Surgery & Telemedicine, India
3MBBS, MS General Surgery (JIPMER), Senior Resident, Department of Plastic Surgery, Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER), India
*Ravi Kumar Chittoria, MCh, DNB, MNAMS, FRCS (Edin), DSc, PhD(Plastic Surgery), Professor & Registrar (Academic),Head of IT Wing and Telemedicine, Department of Plastic Surgery & Telemedicine, India
Abstract
Flap cover tissue techniques constitute one of the major pillars in rehabilitative surgery, and remain vital in helping restore form and function to patients. However, their success is threatened by the occurrence of flap necrosis. Thus, it is imperative to probe techniques to prevent aforesaid necrosis. We report our experience of using infiltration of Autologous Platelet Rich Plasma (APRP) to help in prevention of flap necrosis.
Key words: Autologous Platelet Rich Plasma, APRP, flap necrosis, prevention
Introduction
The flap cover technique is one of the most widely utilized procedures in plastic surgery, applicable in both trauma reconstruction and oncological cases. Groin flaps lie at the very core of this edifice as they were amongst the first successful free flaps to ever be executed [1]. Flap loss, whether partial or complete, is a significant complication that is often feared. This can arise from various patient-related factors, including local wound complications and general health issues like advanced age, diabetes, and a history of smoking. Furthermore, surgeon-related factors—such as the technique used, the positioning of the patient after surgery, and any compression on the pedicle—can also contribute to this risk [2]. One of the pivotal factors contributing to flap loss is flap necrosis. To reduce its incidence , it is essential to optimize the patient's condition and follow precise techniques when raising and managing the flap. To combat this dreaded complication, one novel method which we would like to explore is the application of autologous platelet-rich plasma to the edges of the flap to help prevent necrosis.
Materials and methods
The study was conducted in the Department of Plastic Surgery in a tertiary care centre, during the month of October 2024 after having obtained informed consent and prior approval from the institutional ethics committee. The patient was a 15 year old male with history of having sustained scald burn injuries to his left hand, left leg and both of his feet 12 years ago. He was then conservatively managed for the same, with concomitant intravenous fluids, analgesics and antibiotics. The patient had no history of usage of either adequate splinting or rehabilitative physiotherapy corresponding to his injuries. He then proceeded to develop a fixed flexion deformity which progressively worsened with the growth of the child. The patient had an inability to lift or grip heavy objects with his left hand and was unable to straighten the fingers in the same due to severe post burn contractures. He presented to our institution for correction of post burn contractures in his left hand, left leg and bilateral feet.
He subsequently underwent contracture release of the left hand with release of the 2nd, 3rd,4th and 5th with bipedicled tubed graft of the left groin with infiltration of Autologous Platelet Rich Plasma(APRP) injected subcutaneously around the flap margin to prevent flap necrosis. A standardized and validated APRP technique, as described by Franco et al [3] and Li et al was utilized to produce APRP . The preparation involved the following steps: 10 mL of the patient’s heparinized venous blood was drawn and centrifuged at 3,000 RPM for 10 minutes. The upper layer from the three layers formed was then collected and centrifuged again at 4,000 RPM for another 10 minutes. This procedure resulted in two distinct layers. The lower layer, which contained a high concentration of platelets, was aspirated using an 18-gauge needle and then infiltrated subcutaneously around the flap margins.
Results and Discussion
There was no evidence of flap necrosis for the patient after 1 week.
Autologous Platelet Rich Plasma (APRP) was initially introduced by hematologists to manage thrombocytopenia in haemophilia [4]. Over the next few decades, its utility has grown multifold, finding purpose in sports medicine and aesthestic medicine [5]. Its burgeoning apllication as an adjuvant in preventing flap necrosis is now being slowly explored. Its main action in doing so rests on the wide gamut of growth factors it contains; such as platelet-derived growth factor (PGDF), transforming growth factor (TGF) –beta, vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), Insulin-like growth factor (IGF)-1, fibroblast growth factor (FGF) [6-9]. These provide a favourable environment to promote angiogenesis and encourage cell division and cell migration to the site of application. These growth factors are thus accumulated in supranormal concentrations whenever APRP is applied and hence are crucial in preventing flap necrosis.
APRP has also been shown to encourage the growth of human dermal fibroblasts, leading to increased deposition of type I collagen, which supports flap adherence and healing.
Figure 1: Infiltration of APRP into the donor area.
Figure 2: Infiltration of APRP into the donor area.
Conclusion
In conclusion, we may observe that APRP certainly has a major part to play in reducing the occurrence of flap necrosis; thereby preventing the incidence of one of the most insidious complications of flap placement. A larger, multicentric trial is definitely worth looking into in order to validate the same and improve patient outcomes.
