References

1. Jennette JC, Falk RJ. Small vessel vasculitis. N Engl J Med 1997;337:1512e23.

2. Saulsbury FT. Henoch Schonlein purpura in children. Report of 100patients and review of the literature. Medicine 1999;78:393e409.

3. Al-Sheyyab M, El-Shanti H, Ajlouni S, et al. Henoch-Schonleinpurpura: clinical experience and contemplations on a strepto-coccal association. J Trop Pediatr 1996;42:200e3.

4. Rodriguez-Ledo P, Gonzalez-Gay MA. Henoch-Schonlein purpurain children from northwestern Spain. A 20-year epidemiologicand clinical study. Medicine 2001;80:279e90.

5. Kilmer SL, Wheeland RG, Goldberg DJ, Anderson RR, editors. Treat-ment of epidermal pigmented lesions with the frequency-doubledQ-switched Nd:YAG laser. A controlled, single-impact, dose-response, multicenter trial. Archives of Dermatology, December1994;vol. 130. No 12, Department of Dermatology, Wellman Labo-ratories of Photomedicine, Harvard Medical School, Boston, MA.

Preetham KodumuriHamid TehraniSehwang Liew

Cath GorstAlder Hey Royal Liverpool Children’s Hospital, Liverpool, UK

E-mail address: dr.preetham.k@gmail.com

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.03.069

Figure 1 Hypertrophic hyperpigmented scars due to HSP.

Figure 2 Blisters 3 days after the LASER treatment.

Figure 3 Deroofed blisters.

Correspondence and communications 1565

Reconstruction of lower leg skin ulcer with autologousadipose tissue and platelet-rich plasma

The process of wound healing in intractable lower leg ulcers ismediated by a complex arrayof intracellular and extracellularevents, the intricate nature of which is not yet clear.1

1566 Correspondence and communications

A full-thickness defect of the soft tissue, without expo-sure of important structures such as vessels, nerves,tendons and bones, is treated traditionally with a split-thickness skin graft. However, wounds with poor granula-tion are resistant to skin grafts. In this situation, anotheroption would be the use of dermal substitutes and regen-erative medicine now represents a new treatment for skinulcers. The present study focuses on the clinical use ofautologous adipose tissue and autologous platelet-richplasma to evaluate their biological properties in the wound-healing process and confirmed its usefulness in the treat-ment of skin ulcers. The adipose tissue contains multi-potential cells and adipose-derived stem cells.2

A 65-year-old man, ex-chronic smoker, presented witha lower leg chronic skin ulcer (Figure 1a) following a skintrauma, present for approximately 3 years. He was alsohospitalised for a thrombophlebitis of the right lowerextremity. No other illnesses were reported. Although it wasnot fatal, this chronic wound severely affected his quality oflife. In the past, the patient had to undergo numerousmedical and surgical treatments (dressing, local drug appli-cations, room hyperbaric oxygen, surgical debridements).

The cure was very cost effective for the patient. Wedecide to enroll him in this study.

We took an amount of adipose tissue from his abdominalwall via liposuction and an amount of his blood. The patientsigned an informed consent for a blood sample, not to beused for blood transfusion, and he gave his informedconsent for the operation. Platelet-rich plasma fromautologous blood and autologous fatty cells were mixeduntil a parenchymal consistency was obtained (Figure 1b).

This autologous dermal substitute was applied to the ulcerbed after surgica debridement (Figure 1c). Four weeks aftersurgery, the local area before the skin graft is shown inFigure 1d. The split-thickness skin graft is shown in Figure 2a.The graft took well (Figure 2b) without local infection or other

complications. The donor site of the adipose tissue and thedonor site of the skin graft (Figure 2c) had minimal morbidity.

To date, 15 months later (Figure 2d), the skin of the localarea is well healed and functional. The quality of life of thepatient is completely changed.

The conventional treatment for skin ulcers involvesmedical therapy to improve the vitality of the soft tissuessurrounding the defect, and a surgical approach (wounddebridement, vacuum-assisted closure (VAC) system,dermal substitutes, skin graft), but sometimes surgery doesnot work. In this case we used autologous adipose tissue3 inassociation with autologous platelet-rich plasma,4 whichshow strongly enhance granulation tissue and improve localvascularisation.5 We placed our dermal substitute in thedefect area and waited 4 weeks (time of establishment)before split-thickness skin grafting, which is the disadvan-tage of this technique. The advantages of this techniqueinclude: inexpensive method, the use of autologous tissuesand the absence on the donor site of a full-thicknessdefect. The growth factors derived from platelets can beused to stimulate cell proliferation; they also contain animportant endogenous stimulator of angiogenesis.4 Webelieve that these biological factors, in association with thebenefits of multipotent cells contained in the adiposetissue, accelerate the healing of chronic skin defects.

We believe that this method for the reconstruction ofa venous ulcer of the inferior limbs can also be used in otherareas of the body which need reconstruction of dermal tissue.

In conclusion, we treated a lower limb ulcer, which wasresistant to conventional conservative and surgical reme-dies, using autologous adipose tissue and autologousplatelet-rich plasma to enhance granulation tissue beforeskin grafting. Our dermal substitute encourages the survivaland adaption of the skin graft to the bed of the wound.

There were several follow ups in months 1, 3, 6 and 15.The condition of the leg skin area was already improved in

Figure 1 (a) Chronic skin ulcer of the leg. (b) The mixture of platelet-rich plasma, fat and cryoprecipitate is heated at 37 �C for3 min in a sterile steel container. It has acquired a parenchymal consistency. (c) The new tissue obtained is cut and put on to theulcer bed. The dermal substitute is anchored with sutures on to the skin margins. (d) Immediately before the skin graft.

Correspondence and communications 1567

Figure 2 (a) Split-thickness skin graft. (b) The local area 3 weeks later. (c) The skin graft donor site (right thigh). (d) The localarea of the leg 15 months later.

Giant cell reparative granuloma of the orbits, maxillaeand mandible

Giant cell reparative granuloma (GCRG) is an uncommonbenign lesion usually involving the mandible and maxillaand, very rarely, the orbit. The lesion is found predomi-nantly in children and young adults below the age of 30years and is more common in females. GCRG involving thejaw was first reported by Jaffe1 who separated it from theother giant cell lesions of the bone. There is a great vari-ation in the clinical presentation of the tumour. The mostcommon presentation is a jaw swelling associated withloosening of the teeth, with or without pain.2 Orbitalinvolvement is very rare with resulting proptosis, exoph-thalmos or blurring of vision. A GCRG case with unusualbilateral orbital involvement is presented in this study.

A 13-year-old girl presented with a history of facialswelling that had started 5 years previously (Figure 1a). Theswelling had initially involved the maxilla on the right sideand after 2 years had progressed to the mandible. For thepast 2 months she had also developed proptosis andimpairment of vision in the right eye.

Clinically, there was an irregular bony swelling involvingboth maxillae and the left side of the mandible, with proptosis

the first month. The tactile, thermal and pain sensibilitycould not as yet be valued. The patient started walking 2weeks after the skin grafting without pain and in a goodphysical and psychological condition. We strongly suggestthat the use of platelet-rich plasma and fatty cells representsan efficient therapeutic method for chronic skin wounds. Theapplication of the autologous adipose tissue and platelet-richplasma on the lower leg ulcer seemed to accelerate thewound-healing process. However, the mechanism and theprotocol of this method have not yet been optimised.

References

1. Rodriguez AM, Elabd C, Amri EZ, et al. The human adipose tissue isa source of multipotent stem cells. Biochimie 2005;87:125e8.Review.

2. Eppley BL, Pietrzak W, Blanton M. Platelet-Rich plasma:a review of biology and applications in plastic surgery. PlastReconstr Surg 2006;118:147e59.

3. Fu X, Fang L, Li H, et al. Adipose tissue extract enhances skinwound healing. Wound Repair Regen 2007;15:540e8.

4. Knox RL, Hunt AR, Collins JC, et al. Platelet-rich plasmacombined with skin substitute for chronic wound healing: a casereport. J Extra Corpor Technol 2006;38:260e4.

5. Helder MN, Knippenberg M, Klein-Nulend J, et al. Stem cellsfrom adipose tissue allow challenging new conceptsfor regen-erative medicine. Tissue Eng 2007;13:1799e808. Review.

Salvatore SalemiCristina Rinaldi

Department of Plastic and Reconstructive Surgery,Transfusion Blood Service, Udine University,

Surgery Department, Pediatric Hospital,‘‘Burlo Garofolo’’, Trieste, Italy

Francesco MannaSurgery Department, Maternal Child Hospital,

‘‘Burlo Garofolo’’, Trieste, ItalyE-mail address: framan64@gmail.com

Gianni Franco GuarneriPier Camillo Parodi

Department of Plastic and Reconstructive Surgery,Transfusion Blood Service, Udine University,

Surgery Department, Pediatric Hospital,‘‘Burlo Garofolo’’ Trieste, Italy

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.04.048