BARBARA, Maurizio

CAVALLINI, Marco

MACRI C

MURE C

PAVAN, Antonio

VOLPINI L

English

Archivio della ricerca- Università di Roma La Sapienza

Int. Adv. Otol. 2009; 6:(1) 89-9389Objective: To test the use of autologous platelet gel for repairing skin defects following BAHA surgery.Background: Application of autologous platelet gel was shown to be successful for treating skin defects in diabetic patients aswell as in orthopedic surgery.Materials and Methods: Two of a cohort of 33 patients, who have undergone BAHA placement by using different skinincisions, presented with a skin defect around the titanium abutment. Autologous platelet gel was prepared as a complexconcentrate at the ImmunoHematologic Laboratory of the same University Hospital. The procedure included blood withdrawalfrom the same patient, to which thrombin, Ca-gluconate 10% and ethanol 96% were added. The protocol consisted in 1application per week, for six weeks, to be eventually repeated in case of unsatisfactory results.Main Outcome Measures: Objective photo-documentation was carried out during the protocol period.Results: In both cases, complete resolution of the skin defects was achieved after the first cycle of application.Conclusion: Although success in BAHA implantation resides on an appropriate osteointegration process, other issues mayarise which could jeopardize the final outcome and/or postpone the device activation, such as skin health conditions aroundthe abutment. The use of autologous platelet gel has shown to produce a definitive healing of the defect area, and it allowedavoiding delayed activation or explantation.Submitted : 12 August 2009 Accepted : 12 November 2009IntroductionSince the first clinical report on Bone-AnchoredHearing Aids (BAHA) in 1981 [1], this system hasbecome a well-established and successful method forauditory rehabilitation of conductive and mixedhearing loss, as well as profound unilateralsensorineural hearing loss, i.e. single sided deafness(SSD). Initial concerns for a percutaneous abutmenthave largely been compensated by reproduciblesuccess rate, high patient satisfaction and lack ofserious complications.The key point in BAHA surgery is the realization of acorrect process of osteointegration between titaniumscrew and patient’s skull, a biological, time-dependantprocess. Casistics from the major BAHA Centresindicate the possibility of rare, still possiblecomplications, which are often involving the skinaround the abutment, such as granulations, skinovergrowth and flap necrosis [2-6]. Bone and soft tissuecomplications seem, however, not to be completelyseparate, because loss of BAHA abutment has alsobeen related to a poor post-operative skin healing [2].In the field of wound healing, new-generationtreatments, such as platelet (PLT)  gel, have recentlybeen introduced in the therapeutic repertoire, fortreating soft tissue ulcers in diabetic patients [7], fortissue reconstruction in facial plastic surgery [8] andOphthalmology [9]. This latter application has beenORIGINAL ARTICLEUse of Platelet Gel For Skin Defects After BAHA ImplantationMaurizio Barbara, Claudio Macrì, Carmelo Murè, Luigi Volpini, Marco Cavallini , Antonio PavanUniversity Sapienza, II Medical School, Rome, ItalyDepartment of Neuroscience, Mental Health and Sensory OrgansDepartment of Surgery, (MC)Department of Clinical and Molecular Medicine, (AP)Corresponding address:Maurizio Barbara MD PhDDepartment of Neuroscience, Mental Health and Sensory Organs Sapienza University, II Medical School Azienda Ospedaliera Sant’Andrea Via diGrottarossa 1035, 00189 Rome ItalyFax: +39 06 33775058; E-mail: maurizio.barbara@uniroma1.itCopyright 2005 © The Mediterranean Society of Otology and Audiology90The Journal of International Advanced Otologybased on the possibility that PLT-derived factors, suchas PLT-growth factors and fibroblast growth factors,may also up-regulate growth of dense-tissue cells, suchas chondrocytes, osteoblasts and periosteal cells [10].The present report regards a proposal of treatment ofskin defects occurring around the abutment afterBAHA surgery, which has been applied to two patientsand allowed to achieve a perfect healing so as tosuccessfully activate the implant.Material and MethodsSince February 2005, 33 subjects (13 males, 20females, aging between 16 and 74 years) received aBAHA system at a tertiary referral Centre (UniversityHospital).Surgical technique regarding skin incision changedover time, being first performed via a manual U-shaped flap in 5 patients, subsequently via aDermatome in 18 patients and via a simple linearincision in the last 10 patients.In two out of the “Dermatome” group of BAHAimplantees, alteration of the skin healing processaround the abutment was early observed, ending upwith the exposure of bare bone which delayedactivation of the device and/or jeopardize the wholerehabilitative procedure. After initial attempts withlocal medications, including iodine solutions andsilver nitrate cauterization, the possibility to useapplications of autologous platelet gel was considered.   The platelet gel is a complex concentrate produced atthe ImmunoHaematology and Transfusion Unit of thesame University, according to a standardized protocol [11].The procedure includes blood withdrawal from thesame patient, ultracentrifugation in order to isolate theplatelets, addition of thrombin, 0.22 mol/L Ca++-gluconate and ethanol 96%, and storage of the finalsubstance at -4° C for 30 minutes.The procedure followed was in accordance with theethical standards of the Committee on HumanExperimentation of Medical Faculty, SapienzaUniversity and with the Helsinki Declaration (JAMA2000;284:3043-3049). The patients signed aninformed consent before undergoing the wholeprocedure. Before application, the substance was putat room temperature and the patient asked to lie insupine position with the head turned towards theunaffected side.  After disinfection and debridement ofthe wound edges, the platelet gel was poured from asyringe, at room temperature, on the site to be treated,and left in place for 10 minutes. The protocol consistsin cycles of one application per week, for 6 weeks. Anadditional cycle is planned in case of incompletewound healing.Case 1A 57-years old diabetic, Caucasian man, presentingwith profound unilateral sensorineural hearing lossfollowing subtotal petrosectomy for petrous bonecholesteatoma surgery, was planned for BAHArehabilitation as a SSD case. A Dermatome pedicledflap was used. Since the first post-operative days,granulation tissue was observed around the abutment,thus requiring daily medications with iodine solutionsand packing with Connectivine® gauzes. Despite thisintense care, a large defect remained, which ended upin the exposure of the underlying bone and forced topostpone implant activation. PTL-gel application washence planned and carried out, allowing a satisfactoryresult after 1 cycle (Figure 1a-b).Case 2A 75-years old Caucasian woman, suffering frombilateral mixed hearing loss due to long-standingchronic middle ear disease, which required multipleoperations without functional recovery, was selectedfor BAHA rehabilitation. A manual U-shaped flap wasused. One month after surgery, just before the plannedactivation of the device, the skin around the abutmentbegan to appear unhealthy, with formation ofgranulation tissue that was at first treated by usingdaily local medications. Owing to the lack of efficacy,it was then decided to proceed with  PTL-gelapplication, obtaining a satisfactory healing result afterone cycle (Figure 2a-b).DiscussionAmong the possible complications from BAHAsurgery, those involving the skin around the abutment,90such as skin overgrowth or skin necrosis, represent themost frequent ones, and are currently staged accordingto Holgers [12] between Grade 0 (no adverse reaction)and Grade 4 (inflammation/infection resulting in theremoval of the abutment). The reason for these minorcomplications seems to be partly due to the merecontact between skin edges and a foreign body, such asthe abutment screw; partly to unfavourable local orgeneral conditions of the patient. In this regard, it mustbe stressed the importance of thoroughly carrying outthe standardized operative steps, mainly the accuratethinning of the skin by reducing the redundant softtissue [13,14]. It may be logical to assume that, whenapplying the abutment close or in correspondence withscar tissue from previous surgeries, the risk for such acomplication may increase. As a matter of fact, the twopatients included in this report had previouslyundergone ear surgery, i.e. multiple tympanoplastiesand subtotal petrosectomy, respectively. In addition,one patient was also diabetic. Although both of themhad received a “Dermatome” incision, it would notseem plausible to assume that this type of technique ismore likely to favour this complication.Wound healing is a process that involves different celltypes, growth factors and other proteins, which interactwith each other leading to a fast, efficient repair of the91Use of Platelet Gel For Skin Defects After BAHA ImplantationFigure 1. Case 1 patient: a) early post-operative skin defect around the abutment; b) skin healed after platelet gel application protocol iscompletedA BFigure 2. Case 2 patient: a) skin granulations around the abutment occurring one month after surgery; b) skin healed after platelet gelapplicationA Blesion [11]. Platelets play a primary role in tissuerepair/regeneration not only because of theirhaemostatic properties, but also because of theircapability to release a series of growth factors involvedin the repair of the lesion. For this reason, the use ofblood components, especially from the sameindividual (autologous), has been rapidly extended tovarious clinical settings.As already mentioned, among the various bloodcomponents available for topical use, platelet gel hasdrawn particular interest since it could generategrowth factors able to stimulate tissue regenerationand repair. As a matter of fact, due to its high plateletconcentration, platelet gel contains a large amount ofgrowth factors released by activated platelets, such asplatelet-derived growth factor, tumor growth factor-(,vascular endothelial growth factor, insuline-likegrowth factor and basic fibroblast growth factor,obtained by degranulation of the platelets. Oncesecreted, these factors bind to their respective receptorand activate cells in the surrounding tissues, thuscontributing to the repairing process of a lesion.Many studies have also shown that platelet gel is ableto induce proliferation of fibroblasts, endothelial cellsand also osteoblasts, a predominant cell type present inthe skull, where BAHA titanium screw is going to beimplanted.In BAHA surgery, the possibility of a skin defect canbe due to the interface with a foreign, thoughbiocompatible, body, which in addition needs to beintegrated within the skull. This double integrativeprocess may be at risk in case of general (diabetes,etc.) or local (previous surgery) negative factors. Also the process of osteointegration involves growthfactors (TGF-α, IL-1 and IL-2) for a good response tothe inflammation at the unsterile site of contactbetween bone and titanium. This is the reason why, inthis specific type of surgery, platelet gel could be veryhelpful, as demonstrated in the two patients object ofthe present report.It is possible to conclude that skin defects, which couldhypothetically jeopardize the final outcome in BAHAsurgery, may be successfully treated by localapplication of PLT-gel. This laboratory product shouldtherefore be considered a useful implementation in thearmamentarium of Centres involved in this hearingrehabilitative procedure.References1. Tjellstrom A, Lindstrom J, Hallen O, Albrektsson T,Branemark PI. Osseointegrated titanium implants inthe temporal bone. A clinical study on bone-anchoredhearing aids. Am J Otol 1981; 2:304-10.2. Wazen J, Young DL, Farrugia MC, ChandrasekharSS, Ghossaini SN, Borik J, Soneru C, Spitzer JB.Successes and complications of the BAHA system.Otol Neurotol 2008; 29:1115-19.3. Reyes RA, Tjellstrom A, Grangstrom G. Evaluationof implant losses and skin reactions around theextraoral bone-anchored implants: a 0- to 8-yearfollow-up. Otolaryngol Head Neck Surg 2000;122:272-76.4. House JW, Kutz JW jr. Bone-anchored hearing aids:incidence and management of post-operativecomplications. Otol Neurotol 2007; 28:213-17.5. Shirazi MA, Marzo SJ, Leonetti JP. Perioperativecomplications with the bone-anchored hearing aid.Otolaryngol Head Neck Surg 2006; 134:236-39.6. Tjellstrom A, Grangstrom G. How we do it:frequency of skin necrosis after BAHA surgery. ClinOtolaryngol 2006; 31:216-32.7. Mazzucco L, Medici D, Serra M, Panizza R, RivaraG, Orecchia S, Libener R, Cattana E, Levis A, BettaPG, Borzini P. The use of autologous platelet gel totreat difficult-to-heal wounds: a pilot study.Transfusion 2004; 44:1013-18.8. Banoth S, Alex JC. Current applications of platelet-gels in facial plastic surgery. Facial Plast Surg 2002;18:27-32.9. Gehring S, Hoerauf H, Laqua H, et al. Preparation ofautologous platelets for the ophthalmologic treatment ofmacular holes. Transfusion 1999; 39:144-48.92The Journal of International Advanced Otology93Use of Platelet Gel For Skin Defects After BAHA Implantation10. Okuda K, Kawase T, Momose M, et al. Platelet-rich plasma contains high levels of platelet-derivedgrowth factor and transforming growth factor-beta andmodulates the proliferation of periodontally relatedcells in vitro. J Periodontol 2003; 74:849-57.11. Rughetti A, Giusti I, D’Ascenzo S, Leocata P,Carta G. Pavan A, Dell’Orso L, Dolo V. Platelet gel-released supernatant modulates the angiogeniccapability of human endothelial cells. Blood Transfus2008; 6:12-17.12. Holgers KM, Tjellstrom A, Bjursten LM,Erlandsson BE. Soft tissue reactions around thepercutaneous implants: a clinical study on skin-penetrating titanium implants used for bone-anchoredauricular prosthesis. Int J Oral Maxillofac Implants1987; 2:35-39.13. Proops DW. The Birmingham bone anchoredhearing aid programme: surgical methods andcomplications. J Laryngol Otol 1996; 21:7-12.14. Stalfors J, Tjellstrom A. Skin reactions afterBAHA surgery: a comparison between the U-graft andthe BAHA dermatome. Otol Neurotol 2008; 29:1109-1114.

Use of Platelet gel for skin defects after BAHA implantation

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Use of Platelet gel for skin defects after BAHA implantation

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