European Journal of Cardiovascular Medicine

Skin grafting has been in use for several thousand years to recur desultory defects of several forms in the treatment of large soft tissue defects. Split skin graft is a preferential method of treatment due to its ease in harvest and application. By harvesting skin graft, vascular supply is cut off thus graft depends on the wound bed for nutrition and survival. Skin graft healing occurs in 3 phases: anchorage, inosculation, and maturation. These phases mimic the stages of wound healing, which are hemostasis, inflammation, proliferation, and remodeling¹.

In the initial phase, to protect nutrient supply and graft moisture, close apposition of the graft to recipient wound bed is essential till revascularization occurs in the second phase. Activation of platelets and degranulation in the wound bed in PRP leads to production of fibrinogen later converted to fibrin is the main component in anchoring skin graft and wound bed. 

Infection, hematoma, seroma, and mechanical shearing force in the initial two phases which can disrupt the contact between skin graft and wound bed leading to severance of nutrient supply causing graft failure. It is important to have a wound bed with clean healthy granulation tissue to prevent infection. Meshing of the graft prevents hematoma or seroma formation. Compression dressing over the grafted site will limit the mechanical shearing force. Application of PRP over wound bed before resurfacing the skin graft provides immediate skin graft anchorage as well as inosculation to graft with nutrient rich blood media. Autologous PRP mimics the final step of coagulation cascade which helps in stabilizing hemostasis and prevents collection under the graft or undue shearing forces by its instant adhesion property².

This study aims at comparing between conventional mechanical fixation and topical application of Autologous platelet rich plasma in wound bed during skin grafting and to assess parameters in both groups i.e. instant adhesion, hematoma, discharge from graft site with significant graft loss, graft edema, frequency of dressings and duration of hospital stay.

A comparative study was conducted in the department of General Surgery of a tertiary care centre for a period of 15 months. Patients   who were posted for split skin grafting after obtaining informed and written consent in understandable language were subjected to the study. Patient

aged between 18 and 75 years, with acute and chronic traumatic post burn wounds, patients with co morbidities like diabetes and hypertension and those on aspirin analogues were included. Those with coagulation disorders and malignancy, those with severe co morbid illness and Immunocompromised status were excluded from the study. A universal sampling technique was used to recruit the study subjects. Out of 147 cases reported during the study period, 100 cases who met inclusion criteria were selected. Random allocation of the subjects into two groups, group-1: PRP and group-2: control was done by using the coin flipping method after obtaining informed and written consent and anonymity was maintained.   In the PRP group, autologous platelet rich plasma was applied topically over the wound bed before resurfacing the graft. In the control group, skin graft is fixed to the wound bed with conventional method(sutures). Outcome assessor blinded to prevent detection bias.

A thorough preoperative preparation was done in both the groups. In the study group, autologous PRP (Platelet Rich Plasma) was done on the day of surgery. Under aseptic precaution, blood was drawn preferably from the femoral vein in a 50ml disposable syringe. Blood is transferred into 10ml sterile test tubes which contain 1ml of CPD-A which was freshly obtained from the blood bank. 6ml of venous blood is transferred to 2 to 3 test tubes containing CPD-A. Whole blood is centrifuged at low rpm and shorter duration (1000rpm X 10min) called soft spin which will separate the blood into: bottom most RBC layer accounts for 45% of total volume and top most platelet poor plasma (PPP) accounts 40 for 50% of total volume and an intermediate buffy coat accounts for 5% of total volume contains PRP. PPP (Platelet Poor Plasma), PRP (Platelet Rich Plasma) and some RBCs (Red Blood Cells) are transferred to an anticoagulant free test tube using a sterile syringe. This test tube will undergo a second spin with high rpm and longer duration (5000rpm X 25min) called hard spin. This allows platelets and few RBCs to settle at the bottom of the test tube, which is called PRP. About 80% of total volume at the top of the test tube, which is a cellular, platelet poor plasma will be discarded, remaining 20% left at the bottom of test tube is PRP and was shaken well. To produce 5 ml of PRP approximately 30 ml of whole blood was required ³.

Operating procedure:

Wounds were surgically debrided, hemostasis achieved, thorough wound washing was done as a preliminary step for both PRP and control groups. In the PRP group, freshly prepared PRP applied using a syringe over the surface of the recipient site followed by surfacing the split skin graft. Instant adhesion was checked by gently moving the graft from the wound bed by an assistant who was blinded in this study. In the control group, graft fixed using 3-0 nylon. The graft was covered by an antiseptic coated, soft paraffin gauze, and secured with compression dressing (Fig.1).

Assessment:

Conventionally the first look was done within one postoperative week, but indication for change of dressing in our study was wetness of outer dressing, bad smell and pain in both groups.

Graft edema, hematoma, discharge from the graft site, significant graft loss, frequency of dressings and duration of stay in hospital are the objective parameters noted during study.

The ethical clearance was obtained from Institutional ethics committee for the conduct of the study (ECR No: ECR/1147/INST/PY/2018).

STATISTICAL ANALYSIS:

The proportion of patients revealing instant adhesion, graft edema, discharge from the graft site, hematoma with significant graft loss, scar hypertrophy was calculated for each of the groups. Similar computations were done between control and PRP group with regard to day of first graft inspection, frequency of post-operative dressings and hospital stay. Quantitative data is presented with the help of frequencies, mean and standard deviation. Association among the study groups is assessed with the help of Chi-Square test or Fischer exact test with ‘p’ value less than 0.05 taken as significant.

A Randomized comparative study was conducted in department of General Surgery of a teaching hospital for a period of 15 months. Study subjects were allocated into two groups, Group 1, PRP and Group 2, control. Out of 147 cases, 100 cases who consented to be a part of the study  were selected based on the inclusion criteria. Among the 100 subjects, 20% were female and 80% were male with mean age of male, 53.75yrs and female being 50.3yrs. Most of the study subjects were in the age group of 50-70 years, 54% with an overall mean age being 53.06years. (Fig.2 & Fig.3).

Among the parameters assessed, 100% of instant adhesion was seen in the PRP group. Graft edema was comparatively less in PRP group,13% while in the control group was 59.2%. In the present study the incidence of discharge from the graft was 4.3% in the PRP group as compared to 16.66% in the control group. In PRP group 90.31% of patients had their first inspection of the graft after one week whereas in the control group 71.42% of patients had their graft inspection before a week postoperatively (p<0.05). Majority (80.4%) had only 1-2 dressings in PRP group while in the control group, 94.4% had undergone 3-5 dressings post operatively and even the   duration of stay in hospital post operatively was less in PRP group in comparison to control group, where 80.5% of them stayed for more than 10 days (p<0.05).  All these objective   parameters used for the assessment of efficacy   were found to be significant statistically with p value of < 0.05.  However other parameters like gender, age, presence of co morbidities and hematoma in grafted region did not show any significant differences in both the groups. (Table.1 & Fig.4).

This study was done to compare the efficacy of autologous PRP when applied over wound bed prior to graft placement over the conventional methods. Out of 147 cases who were in need for skin grafting during the study period, 100 cases were included as per the inclusion criteria and among them 46 were selected by random sequence allocation into PRP (Group 1) and remaining 54 into control group (Group 2).  Graft inspection and post-operative change of dressings done as required. Among the parameters assessed instant adhesion of graft was 100% in PRP group while in control group there was no instant adhesion to the wound bed. Similar findings were reported in study conducted by Gupta et al where graft uptake or adhesion was better in intervention (PRP group) than compared to conventional method(p=0.04). Due to healing, adhesive and hemostatic properties of Autologous PRP, it has been used in various treatment modalities to attenuate graft uptake and reduce complications ⁴. In the present study incidence of graft edema was 13% in the PRP group as compared to 59.25% in the control group and similar results were seen in study by Dhua et al and Veena et al where only 10% with graft edema was noted in the PRP treated patients as compared to 68% in the control group. The stage of capillary inosculation and early circulation reduced graft edema with application of PRP^2,5.  Discharge from the graft was only 4.3% in the PRP group as compared to 16.66% in the control group(p=0.049) and hematoma in the grafted region was 2.1% in the study group as compared to 11.1% in the control group. Thimmanahalli GU et al.in their study also reflected a similar result where discharge from graft was 3.3% in autologous PRP group and 20% in control group(p=0.044). Veena et al also reported 4% of the patients in PRP group with hematoma under the graft and required secondary grafting compared to 15% in the control group. Tyagi A et al  in his meta-analysis found decreased hematoma formation in intervention group (PRP)  with pooled Odds ratio of 0.21 (95% CI: 0.09-0.⁵⁰; I²=0%; p=0.869) signifying that PRP use decreased the odds of hematoma formation by 79%.  Growth factors  delivered from PRP serve to accelerate the wound-healing process by increasing cellular proliferation, matrix formation, connective tissue healing, angiogenesis, and collagen synthesis ^5,6,7. Majority,  90.31% of patients had their first inspection of the graft after one week post operatively in study group while 71.42% of patients had their graft inspection before a week postoperatively in controls and  80.4% had only 1-2 dressings in PRP group  while in the control group, 94.4%  had undergone  more than 3-5 dressings. Waiker et al in their study also found 94% of patients in PRP group had undergone first graft inspection after one week⁵. Dhua eta al showed frequent dressings in controls and Girish et al stated 90% patients from control group and only 4% in PRP group needed 3-5 dressings ^2,6. Nearly 80% of them in the control group stayed for more than  10 days in the hospital post-surgery while  most  of  the patients  in PRP group was discharged within 10 days . Fang Z et al, Veena et al, Girish  and       V Raghuram et al also showed a similar findings where autologous PRP group patients showed  improved  wound healing  and reduced hospital stay^5,6,8,9 in comparison to conventional methods. As PRP promotes instant graft adhesion and enhances early vascularization, there are decreased instances of soaked dressings and graft failure due to increased moisture, thereby reducing the total number of dressings and duration of hospital stay remarkably¹⁰.

 As the patients were selected by randomization there is a lesser chance of bias; the findings of the study can be extrapolated and autologous PRP can be used and applied before resurfacing to different type of wound healing therapies. Long term follows up to assess the nature of the scar was not done and is one of the limitations in the current study.

We conclude that it is recommendable to use topical application of autologous PRP prior to resurfacing of split skin graft as it is beneficial in all aspects; provides instant adhesion of the graft, and due to faster rate of epithelization it also decreases the frequency of dressing change, reduces the chances of hematoma, graft loss, reduced hospital stays. By combining PRP with skin grafting; has beneficial results for both patients as well as surgeons by reducing intra operative time and decreased hospital stay. PRP was found to be safe and a cost-effective method in enhancing graft uptake on wounds with a better post operative outcome.

ACKNOWLEDGEMENTS

We would like to acknowledge our study subjects for their support in this study. We would like thank our PGs for their meticulous help rendered during the process of data collection.

CONFLICT OF INTERST: The authors declare no conflict of interest.

SOURCE OF FUNDING: Nil

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