Use of Platelet Gel in Chronic Lower Extremity Ulcers

Sir: The authors treated 20 patients (13 women and seven men, aged between 35 and 75 years) affected by chronic venous insufficiency (i.e., the cause of ulcerations in 60 to 80 percent of patients with chronic leg ulcers) and diabetic foot ulcers with platelet gel mixed with fat tissue centrifuged at the Department of Plastic and Reconstructive Surgery of the “Tor Vergata” University of Rome. On a microscopic level, lymphatic vessels were enlarged and capillaries were elongated and dilated, with the functional number of capillaries being reduced.1 These microscopic changes resulted in the reduction and stagnation of blood flow and decreased oxygen levels at the capillary level in the preulcer skin, and increased flow and arteriovenous shunting in nearby tissues.2 The preoperative study was carried out by means of a complete clinical examination, a photographic examination, and through RM of the tissue. Postoperative follow-up took place after 2 and 5 weeks; 3, 6, and 12 months; and then annually. Platelet gel is a mixture of autologous proteins and contains more than 300,000 to 350,000 platelets/μl, whose action consists of stimulating skin fibroblasts when injected at mixed depth (the authors use 0.5 ml of platelet gel mixed with 1 ml of centrifuged fat tissue) favoring tissue growth by new synthesis of collagen. The authors use a platelet-rich plasma product by Cascade System (Esforax, Rome, Italy). We harvested fat tissue in the abdominal region using some specific cannulas 1.5 mm in diameter. Maintaining asepsis, we took the plungers of syringes and closed them with their cap, and then we positioned them, flatly, in the sterile centrifuge (Coleman technique).3 Fat tissue (processed for 3 minutes at 3000 rpm) mixed with platelet gel is implanted at different levels in small tunnels created previously, forcing the cannula with precise, controlled movements. Small quantities of fat cells are laid, one or two at a time, in the exiting movement of the cannula to create a large grid to favor a correct vascular development around each fat cell.4 In contrast, the authors used conservative treatment that included elevation, local treatment (biosynthetic material), and vacuum therapy. Until recently, this was considered the mainstay of treatment, and its success in achieving ulcer healing has been documented. Ulcer recurrence has been a nagging problem when only conservative treatment has been used. Slow healing and the significant recurrence rate of ulcers given conservative treatment reflect the failure to treat the underlying causative venous hypertension.5 The authors observed that 16 of 20 chronic lower extremity ulcers reepithelialized during a 9.7-week (average) course of twice-daily wound treatment with platelet releasate suspended on a collagen base (platelet-derived wound-healing factor) compared with two of 10 similar wounds treated with placebo. After crossover of the placebo group, all 11 nonhealed wounds achieved 100 percent epithelialization in an average of 7.1 weeks. Collectively, they provide evidence for the clinical use of platelet technology in the healing of both soft- and hard-tissue wounds. The results we obtained prove the efficacy of combining these two treatments, and the satisfaction of the patient confirms the quality of our results. V. Cervelli, M.D. Pietro Gentile, M.D. C. U. Casciani, M.D. Department of Plastic and Reconstructive Surgery “Policlinico Casilino” University “Tor Vergata” Rome, Italy