HAND/PERIPHERAL NERVE

Efficacy of Leukocyte- and Platelet-Rich Fibrin

in Wound Healing: A Randomized Controlled
Clinical Trial
Bérengère Chignon-Sicard,
Background: Application of platelet concentrates to wounds could speed heal-
M.D. ing. Leukocyte- and platelet-rich fibrin, a relatively recent development, stands
Charalambos A. Georgiou, out from the other preparations. This prospective, randomized, controlled
M.D. clinical trial studied the rate of healing of postoperative hand wounds after a
Eric Fontas, M.D. single application of leukocyte- and platelet-rich fibrin.
Sylvain David, M.D. Methods: Eligible patients were healthy individuals older than 18 years who had
Pierre Dumas, M.D. been scheduled for elective McCash (open palm) surgery for Dupuytren disease
Tarik Ihrai, M.D. at the Plastic and Hand Surgery Department of Nice’s University Hospital
Elisabeth Lebreton, Ph.D. between August of 2007 and February of 2010. The control group received the
Nice, France reference care of petroleum jelly mesh (Vaselitulle), and test patients had
leukocyte- and platelet-rich fibrin applied. The primary endpoint was healing
delay measured in postoperative days. Secondary endpoints included pain,
bleeding, and wound exudate. The trial was carried out as a single-blind trial.
Results: Among the 68 randomized patients, 33 patients in the leukocyte- and
platelet-rich fibrin group and 31 in the Vaselitulle group were analyzed. Primary
endpoint analysis showed a median healing delay of 24 days (interquartile range,
18 to 28 days) for the fibrin group and 29 days (interquartile range, 26 to 35
days) for the Vaselitulle group (p ⫽ 0.014, log-rank test). Postoperative pain
assessment, bleeding, and exudate were always lower for the fibrin group, but
not significantly so.
Conclusion: The authors trial demonstrates that a single leukocyte- and platelet-
rich fibrin application on fresh postoperative hand wounds shows a median
improvement of 5 days in comparison with the standard treatment. (Plast.
Reconstr. Surg. 130: 819e, 2012.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

W
ound healing is a very preoccupying and
resource-consuming issue. One of its key
cost drivers is the dressing used,1 and
there is considerable interest in those that may
accelerate healing. During the normal healing
process, platelets play a central role in hemostasis
From the Plastic Reconstructive and Aesthetic Surgery De-
partment, St. Roch University Hospital of Nice, and the
Clinical Research Department, Cimiez University Hospital of
Nice.
Received for publication May 23, 2012; accepted June 28,
2012.
This trial is registered under the name “Evaluation of the
Efficiency of Autologous Platelet Gel (Platelet Rich Fibrin)
Obtained from Own Patients’ Blood versus Vaselitulle in
Dupuytren’s Disease Postoperative Wound Healing,” Clin-
icalTrials.govidentificationnumberNCT00931567(http://
clinicaltrials.gov/ct2/show/NCT00931567).
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31826d1711
and growth factor secretion, inducing the cellular
and tissue proliferation that lead to healing.2 This
has led to the hypothesis that the application of
platelet concentrates to wounds could speed heal-
ing. The use of autologous platelet concentrates as
a perioperative tissue glue with healing properties
was first proposed by Hood in 1993.3 Since then,
a considerable variety of platelet-rich preparations
to accelerate tissue healing have been evaluated,
with encouraging results.4 –7 The use of leukocyte-
and platelet-rich fibrin concentrate8,9 is a relatively
recent development, standing out from the other
preparations because of the procedure’s simplic-
ity, low cost, and healing potential. It is easily ac-
quired with a simple venipuncture and prepared
Disclosure: The authors have no conflicts of inter-
est to declare.

www.PRSJournal.com 819e
 Plastic and Reconstructive Surgery • December 2012
in a standard centrifuge without any complex ma-
nipulations or additives. Its unique three-dimen-
sional structure acts as a reservoir of platelets,
leukocytes, and growth factors that persist in the
application site, giving a prolonged action supe-
rior to that of other preparations.10 Encouraging
in vitro results11 assessing cellular proliferation
and differentiation and favorable in vivo effects
have been obtained, especially in oral surgery.12,13
However, these publications report small series
that have focused on gingival and bone healing.
To our knowledge, no randomized controlled
clinical trial has evaluated the efficacy of leuko-
cyte- and platelet-rich fibrin on fresh skin defects.
We have designed this study to test the hypothesis
that the use of leukocyte- and platelet-rich fibrin
will accelerate healing, leading to improved pa-
tient outcomes and lower treatment costs.
In this trial, we studied the rate of healing of
postoperative hand wounds after a single applica-
tion of leukocyte- and platelet-rich fibrin at the
conclusion of surgery (day 0). The control group
received the current standard care with Vaselitulle
(Solvay Pharma, Suresnes, France) dressings. Post-
operative pain, bleeding, and exudate were also
evaluated.
PATIENTS AND METHODS
Trial Design
This study was a prospective, randomized, con-
trolled, single-blind clinical trial. Initially designed
as a two-center study, the trial was eventually con-
ducted only in a single center because of a lack of
recruitment in the second center. The local ethics
committee and the national health authority
(French Agency for the Safety of Health Products)
approved the protocol. It was conducted in accor-
dance with the principles of the 1996 Declaration
of Helsinki on good clinical practice standards.14
Participants
Eligible patients were healthy individuals
older than 18 years without any comorbidity who
had been scheduled for elective McCash (open
palm) surgery for Dupuytren disease. They were
recruited from the outpatient clinic of the Plastic
and Hand Surgery Department of Nice’s Univer-
sity Hospital between August of 2007 and February
of 2010. Patients allergic to one of the dressing’s
components, with diabetes mellitus type 1, who
were undergoing cancer treatment, who were
pregnant, or who were unable to participate in
follow-up visits were excluded. Patients were en-
rolled after giving their written informed consent.
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Interventions
Fresh postoperative wounds were chosen for
this trial to eliminate possible biases arising from
the chronicity, bacterial colonization, and vascular
insufficiency that can be found in other types of
wounds such as lower extremity ulcers or pressure
ulcers. Various postoperative skin defects were
considered, such as flap donor site and skin graft
donor site, but hand skin defects were more fre-
quent, standardized, and applicable. The McCash
procedure15 (open palm technique) is commonly
performed in our clinic. After fasciectomy, a trans-
verse palm wound is left to heal spontaneously,
avoiding laborious skin flaps or grafts. The tech-
nique has lower rates of joint contracture and
morbidity than other closure techniques (flaps or
grafts), but has the significant disadvantage of re-
quiring a longer healing period. This meant that
these patients were ideal candidates for this trial.
Leukocyte- and platelet-rich fibrin platelet
concentrate was used. It was acquired at the time
of surgery according to the Nice Process PRF
protocol.16 Blood was drawn by venipuncture in
four 9-ml glass-coated tubes with no anticoagulant
and immediately centrifuged at 2700 rpm (400 g)
for 12 minutes. The fibrin clot was then collected
and cut at the erythrocyte zone as close as possible
to the fibrin clot (Fig. 1). After isolation, the clot
was compressed between two sheets of gauze to
obtain four uniform membranes (Fig. 1) that were
then used to cover the operative wound (Fig. 2).
At this point, the clinic’s photographer took a
standardized, scaled photograph of the wound. A
nonadherent dressing and the gauze used to com-
press the clot were then applied over the mem-
branes. Patients randomized to the control group
received the reference care that consisted of the
application of petroleum jelly mesh (Vaselitulle).
Patients were instructed not to remove the dress-
ing until the first appointment and to contact the
clinic in case of abnormal discomfort or pain.
The decision to use this particular autologous
platelet concentrate was based on the procedure’s
simplicity, the absence of biochemical blood mod-
ification [no anticoagulants or activators of coag-
ulation (e.g., calcium chloride) are needed], con-
venience, and cost-effectiveness. Coagulation is
activated on contact with the glass tube, and fi-
brinogen cross-links form progressively in the top
layers of the sample. On centrifugation, this de-
scends to the middle layer and polymerizes to
fibrin, capturing most of the platelets and leuko-
cytes, and platelet growth factors (interleukin-1␤,
interleukin-4, tumor necrosis factor-␣, platelet-de-
Volume 130, Number 6 • Platelet Concentrates and Wound Healing

Fig. 1. (Left) Leukocyte- and platelet-rich fibrin cut-off. The coagulum is cut at the erythrocyte zone as
close as possible to the fibrin clot. (Right) The fibrin clots are compressed between two gauzes to obtain
a uniform membrane that covers the wounds. Liquid that retains growth factors is withheld in the
gauzes after compression, so the same gauzes are placed on top of the leukocyte- and platelet-rich
fibrin to cover the wounds.

presence of leukocytes in leukocyte- and platelet-

rich fibrin. Theoretically, they may destroy growth
factors with metalloproteinases, but proponents of
the technique found that in vivo the leukocytes act
synergistically with platelets and secrete consider-
able amounts of growth factors, especially vascular
endothelial growth factor.21–28 They also improve
resistance to infection, but at the time there is no
definitive evidence to support or reject their use.

Outcomes and Follow-Up

Fig. 2. Patient in the leukocyte- and platelet-rich fibrin group at
postoperative day 2.
rived growth factor A and B, transforming growth
factor-␤1, insulin-like growth factor-1, and vascu-
lar endothelial growth factor), in a “scaffold.”9,17
This three-dimensional bioscaffold17 allows cell
migration, cell differentiation (osteoblasts, kera-
tinocytes, fibroblasts, and preadipocytes), coloni-
zation, neovascularization, and a slow and contin-
uous release of growth factors for up to 14 days
(and longer for certain components) that may be
beneficial in wound healing.10,11,18 –20 There is a
current debate in the literature on the effect of the
The primary endpoint was healing delay mea-
sured in postoperative days. Complete healing was
defined as the day of complete wound epithelial-
ization. A community nurse changed dressings
strictly every 48 hours. This consisted of removing
the superficial layers of the dressing until the non-
adherent dressing. At this point, the nurse care-
fully removed this layer without interfering with
the underlying tissues. This ensured that the leu-
kocyte- and platelet-rich fibrin stayed in contact
with the wound. Every patient was given a docu-
ment in which the nurse noted, at each dressing
change, the wound’s status (healed or not) and
any adverse event. This document also had illus-
trative information on how to evaluate healing
and especially complete wound epithelialization.
The nurse was completely unaware of the trial’s
details, and this helped in obtaining objective ob-
servations. In this way, we could identify the heal-

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 Plastic and Reconstructive Surgery • December 2012
ing day in a relatively objective way with a precision
of 24 hours.
Furthermore, the patients were given a consulta-
tion calendar. They were examined by blinded inves-
tigators on postoperative days 1 or 2, 7, 14, 21, and
28 and on a final visit at postoperative day 60.
These investigators changed the dressing in the
same way as the community nurse, and if the day
of consultation corresponded to the day of dress-
ing change, the nurse was not asked to do the
wound care. They noted healing status in the pa-
tient’s leaflet and verified that dressing changes
were held according to the study’s protocol. In
addition, the investigators were responsible for
secondary endpoint evaluation that was their pri-
mary role in the study. Secondary endpoints in-
cluded pain, bleeding, and wound exudate. Pain
was evaluated using the numeric visual analogue
scale ranging from 0 to 10. Assessment of bleeding
and exudate was by inspection of the gauze, closest
to the wound after dressing removal, using qual-
itative variables (abundant, moderate, slight, or
absent). Abundant was defined as the full gauze
coverage by the wound secretions. Moderate was
defined as partial coverage of more than 50 per-
cent of the gauze, and slight was defined as partial
coverage of less that 50 percent of the gauze. Ex-
udate was defined as the clear wound secretions
that stained the dressings. Exudate usually ex-
ceeded the bleeding limits and thus it was well
identified. If this was not the case, bleeding and
exudate were considered to have the same limits
and abundance.
Sample Size
We estimated that 35 patients for each group
would be enough for the study to have 90 percent
power in detecting a significant difference in heal-
ing delay. This was calculated using the presump-
tion that healing would be 7 days quicker in the
leukocyte- and platelet-rich fibrin group than in
the control group (SD of 929), with a two-sided
alpha level of 5 percent.
Randomization
After meeting selection criteria and giving
written consent, the patients were assigned ran-
domly to either the leukocyte- and platelet-rich
fibrin group or the Vaselitulle group in a 1:1 ratio.
Randomization was performed using sealed, se-
quentially numbered, opaque envelopes contain-
ing treatment allocation according to a pre-
defined randomization list, constructed through
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random permuted blocks (size, 6) by the Nice
University Hospital’s Clinical Research Depart-
ment. Afterward, a clinical research assistant
noted the allocated group in the patient’s case
report file. In this way, the surgeon remained ig-
norant of the patient’s group until the time of
surgery, ensuring allocation concealment and sat-
isfactory randomization.
Blinding
As blood sampling was necessary to achieve the
autologous preparation and as the surgeons ap-
plied the dressing at the operation table, blinding
was only possible for the community nurse that was
responsible for dressing changes and for noting
the day of healing. The investigators responsible
for the secondary endpoints were also blinded.
Thus, this trial was carried out as a single-blind
trial.
Statistical Analysis
Analyses were performed on the intention-to-
treat principle in all randomized patients who un-
derwent the McCash procedure. The analysis of
the primary endpoint, time to healing, was based
on cumulative events curves estimated with the
Kaplan-Meier method; survival curves were com-
pared with the log-rank test. Analysis according to
protocol was also planned, excluding patients lost
to follow-up, using the t test. Evolution of pain was
presented graphically, and comparisons between
the groups were made at days 1, 7, 14, 21, and 28
using the Wilcoxon rank sum test. Bleeding and
exudate were compared at days 7, 14, and 21 using
Fisher’s exact test. No adjustments were made for
multiple significance testing. All tests were two-
sided, and the significance level was set to 5 per-
cent. We used SAS software, version 9.1 (SAS In-
stitute, Inc., Cary, N.C.), for the statistical analyses.
RESULTS
Among the 68 patients who underwent ran-
domization, four were excluded after this stage,
two in each arm, for reasons that were not asso-
ciated with the allocated treatment (Fig. 3). Three
were not treated with the McCash technique or
did not undergo surgery, and one patient was
included twice because of bilateral operation.
Over the study period, three patients were lost to
follow-up but included in the primary analysis ac-
cording to the intention-to-treat principle, for a
total of 33 patients in the leukocyte- and platelet-
rich fibrin group and 31 in the Vaselitulle group.
Volume 130, Number 6 • Platelet Concentrates and Wound Healing
Fig. 3. Flow chart diagram. L-PRF, leukocyte- and platelet-rich fibrin.
All of these patients completed a 2-month follow-
up, and the trial finished in February of 2010.
Baseline characteristics were similar for the
two groups. Patients were mainly men and had a
mean age of 66 ⫾ 7.7 years for the Vaselitulle
group and 61.4 ⫾ 8.8 years for the leukocyte- and
platelet-rich fibrin group. The ring and little fin-
gers of the right hand were typically affected. Du-
ration of disease before surgery was similar for the
two groups, and patients presented mostly in stage
2 Dupuytren disease according to the Tubiana and
Michon classification.30 Interestingly, wound di-
mensions were found to be larger in the fibrin
group (Tables 1 and 2).
Primary endpoint analysis showed a statisti-
cally significant difference between the two
groups, with a median healing delay of 24 days
(interquartile range, 18 to 28 days) for the fibrin
group and 29 days (interquartile range, 26 to 35
days) for the Vaselitulle group (p ⫽ 0.014, log-rank
test) (Fig. 4). The analysis according to protocol
showed the same results with a statistically signif-
icant mean difference of 5.4 days (95 percent con-
fidence interval) between the groups (p ⫽ 0.018).
The number of dressings was lower in the fibrin
group (median, 6; interquartile range, 6 to 8)
compared with the Vaselitulle group (median, 9;
interquartile range, 7 to 12) (p ⬍ 0.001).
Postoperative pain assessment showed relatively
low levels of pain in both groups, but with consis-
tently lower levels in the leukocyte- and platelet-rich
fibrin group. This was observed at every consulta-
tion; however, this difference was not statistically sig-
nificant (Fig. 5). Similarly, bleeding and exudate
were always lower for the fibrin group but not sig-
nificantly so (Tables 3 through 6).
One wound infection was observed in a patient
in the Vaselitulle group. There was one pulmonary
infection in the leukocyte- and platelet-rich fibrin
group, which was not related to the operation or the
operative wound. Apart from these two incidents, no
other complications were noted and the treatment
was well tolerated. Although follow-up was limited,
no abnormal healing (hypertrophic or keloid scar-
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 Plastic and Reconstructive Surgery • December 2012

Table 1. Baseline Characteristics of Patient Groups

Vaselitulle Leukocyte-and Platelet-Rich Fibrin

No. of Patients Values* No. of Patients Values* p

Age, yr 31 66.0 ⫾ 7.7 33 61.4 ⫾ 8.8 0.03†
Weight, kg 31 73.6 ⫾ 11.0 33 76.1 ⫾ 12.3 0.41†
Height, cm 31 169.9 ⫾ 8.1 33 173.8 ⫾ 8.0 0.06†
Sex 31 33 0.43‡
Male 25 (80.7) 29 (87.9)
Female 6 (19.4) 4 (12.1)
Previous surgery 29 6 (20.7) 32 7 (21.9) 0.91‡
Family history 25 8 (32.0) 28 10 (35.7) 0.78‡
Finger 55 63 0.83§
Thumb 2 (3.6) 2 (3.2)
Index 2 (3.6) 2 (3.2)
Middle 5 (9.1) 10 (15.9)
Ring 21 (38.2) 25 (39.7)
Little 25 (45.5) 24 (38.1)
Disease stage, no. (%) 31 33 0.37§
1 10 (32.3) 9 (27.3)
2 15 (48.4) 18 (54.6)
3 5 (16.1) 2 (6.1)
4 1 (3.2) 4 (12.1)
*Values are mean ⫾ SD or no. (%).
†t test.
‡␹2 test.
§Fisher’s exact test.

Table 2. Operation-Related Variables

Vaselitulle Leukocyte-and Platelet-Rich Fibrin

No. of No. of
Patients Value* Patients Value* p
Wound length, mm 30 37.0 ⫾ 14.7 33 44.7 ⫾ 13.8 0.034
Wound width, mm 30 11.3 ⫾ 5.7 33 15.4 ⫾ 6.5 0.010
Dressing number, median (IQR) 21 9.0 (7.0–12.0) 26 6.0 (6.0–8.0) ⬍0.001
IQR, interquartile range.
*Values are mean ⫾ SD or median (IQR).

ring) was observed in either group by the time of the
final consultation. This was confirmed by reviewing
all of the patients’ photographs.
DISCUSSION
Our trial demonstrates that a single leukocyte-
and platelet-rich fibrin application on patients
with fresh postoperative hand wounds following
McCash surgery shows clear benefit in terms of
healing delay. A median improvement of 5 days
was observed in comparison with the standard
Vaselitulle treatment. Dressing changes were
fewer in the fibrin group. This was because of the
faster healing and reflects the regular rhythm of
dressing changes. Treatment with leukocyte- and
platelet-rich fibrin was very well tolerated, and no
important adverse events were noted with it. We
did not observe a significant effect of leukocyte-
and platelet-rich fibrin on bleeding and exudate.
However, patients in the fibrin group had less
bleeding and exudate in every assessment. These
data support the finding of superior healing and
wound epithelialization with leukocyte- and plate-
let-rich fibrin. Similarly, less pain was reported in
the fibrin group, but this did not reach statistical
significance.
In contrast with other studies, this trial inves-
tigated the use of leukocyte- and platelet-rich fi-
brin on fresh postoperative hand wounds in terms
of healing delay. Its closest analogue is the study
by Spyridakis et al.31 that examined the application
of leukocyte- and platelet-rich plasma on fresh
postoperative defects following treatment of pilo-
nidal sinus disease. They observed a comparable
6-day improvement in healing, but comparison
should be cautious because the wound model and
the platelet preparation differ from that of our
study. Other studies5,32–36 of platelet concentrate
application in wound healing have also reported
encouraging results, although two authors showed

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Volume 130, Number 6 • Platelet Concentrates and Wound Healing
Fig. 4. Kaplan-Meier curves of the healing rate. L-PRF, leukocyte- and
platelet-rich fibrin.
Fig. 5. Pain numeric visual analogue scale (VAS) evolution. L-PRF, leukocyte- and platelet-
rich fibrin.
no effect.36,37 These findings are in accord with the
favorable results in our trial, but comparison is
difficult, as the parameters under investigation
(wound type, platelet concentrate, endpoints)
were quite different (Table 7).5,31–38 Furthermore
the nomenclature used to describe the platelet
concentrates in the literature is confusing, making
review difficult. Dohan Ehrenfest et al. proposed
a classification8 according to the presence or ab-
sence of leukocytes and/or fibrin, which seemed
to us suitable to clarify this problem of concentrate
characterization, and we have adopted it in this
article.
A limitation of this study was the fact that,
although originally designed as a multicenter trial,
our study was eventually conducted in only a single
center. Our results may not be generalizable to
patients in other centers using different practices.
However, our population’s relative homogeneity
made for consistent application of the procedures
in our trial.
Another limitation is the single-blind design of
this study, in which treating surgeons and patients
were aware of the treatment received. This was
unavoidable, as control patients had no blood
sampling, and performing blood sampling on the
control patients would have been unethical. The
surgeons placed the leukocyte- and platelet-rich
fibrin in the wound and were thus aware of
which patients had received the active treat-
ment, which could have led to bias in the evalu-
ation of the wounds. However, the follow-up in-
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 Plastic and Reconstructive Surgery • December 2012

Table 3. Postoperative Bleeding Analysis* Table 5. Exudate Analysis*

Leukocyte-and Leukocyte-and
Platelet-Rich Platelet-Rich
Vaselitulle Fibrin Vaselitulle Fibrin

Total Total Total Total

No. of No. of No. of No. of
Bleeding Patients No. (%) Patients No. (%) p† Exudate Patients No. (%) Patients No. (%) p†
Day 7 24 28 0.232 Day 7 24 28 0.107
Absent 13 (54.2) 22 (78.6) Absent 3 (12.5) 9 (32.1)
Slight 3 (12.5) 3 (10.7) Slight 6 (25.0) 11 (39.3)
Moderate 4 (16.7) 2 (7.1) Moderate 11 (45.8) 6 (21.4)
Abundant 4 (16.7) 1 (3.6) Abundant 4 (16.7) 2 (7.1)
Day 14 26 27 0.042 Day 14 26 27 0.004
Absent 18 (69.2) 25 (92.6) Absent 6 (23.1) 14 (51.9)
Slight 2 (7.7) 2 (7.4) Slight 10 (38.5) 8 (29.6)
Moderate 4 (15.4) 0 (0.0) Moderate 9 (34.6) 5 (18.5)
Abundant 2 (7.7) 0 (0.0) Abundant 1 (3.9) 0 (0.0)
Day 21 10 15 0.544 Day 21 10 15 0.524
Absent 8 (80.0) 14 (93.3) Absent 3 (30.0) 7 (46.7)
Slight 2 (20.0) 1 (6.7) Slight 7 (70.0) 7 (46.7)
Moderate 0 (0.0) 0 (0.0) Moderate 0 (0.0) 1 (6.7)
Abundant 0 (0.0) 0 (0.0) Abundant 0 (0.0) 0 (0.0)
*No. of patients does not represent the total number of patients in *No. of patients does not represent the total number of patients in
every group because some patients did not attend accurately the every group because some patients did not attend accurately the
scheduled consultations for the secondary endpoint evaluation. Fur- scheduled consultations for the secondary endpoint evaluation. Fur-
thermore, healed patients were excluded from this analysis (on post- thermore, healed patients were excluded from this analysis (on post-
operative day 21, four patients were healed in the Vaselitulle group operative day 21, four patients were healed in the Vaselitulle group
and 10 patients were healed in the leukocyte- and platelet-rich fibrin and 10 patients were healed in the leukocyte- and platelet-rich fibrin
group). group).
†Test is Fisher’s exact test. Percentages may not total 100 because of †Fisher’s exact test. Percentages may not total 100 because of
rounding. rounding.

Table 4. Binary Analysis after Date Recodification Table 6. Exudate Binary Analysis for Presence or
into Absence or Presence of Bleeding* Absence*
Leukocyte-and Leukocyte-and
Platelet-Rich Platelet-Rich
Vaselitulle Fibrin Vaselitulle Fibrin

Total Total No. of No. of

No. of No. of Exudate Patients No. (%) Patients No. (%) p
Bleeding Patients No. (%) Patients No. (%) p
Day 7 24 21 (87.5) 28 19 (67.9) 0.094
Day 7 24 11 (45.8) 28 6 (21.4) 0.080 Day 14 26 20 (76.9) 27 13 (48.2) 0.031
Day 14 26 8 (30.8) 27 2 (7.4) 0.040† Day 21 10 7 (70.0) 15 8 (53.3) 0.679†
Day 21 10 2 (20.0) 15 1 (6.7) 0.544† *No. of patients does not represent the total number of patients in
*No. of patients does not represent the total number of patients in every group because some patients did not attend accurately the
every group because some patients did not attend accurately the scheduled consultations for the secondary endpoint evaluation. Fur-
scheduled consultations for the secondary endpoint evaluation. Fur- thermore, healed patients were excluded from this analysis (on post-
thermore, healed patients were excluded from this analysis (on post- operative day 21, four patients were healed in the Vaselitulle group
operative day 21, four patients were healed in the Vaselitulle group and 10 patients were healed in the leukocyte- and platelet-rich fibrin
and 10 patients were healed in the leukocyte- and platelet-rich fibrin group).
group). †Fisher’s exact test.
†Fisher’s exact test.

healing and complete wound epithelialization to

vestigators evaluating secondary endpoints were
blinded. More importantly, the community nurse
responsible for dressing changes was also the sole
person responsible for healing evaluation in ig-
norance of the patient’s study allocation. This
helped in providing objective observations and
particularly the healing day, which was the main
endpoint of this study. The nurses were given writ-
ten and illustrative information on how to evaluate
standardize their observations.
Complete wound epithelialization, as the pri-
mary endpoint, was a very debatable subject
among the authors in the trial’s design. Proposals
such as wound measurements were taken into con-
sideration as a means of objective healing evalu-
ation. Although wound measurements took place
perioperatively with the aid of standardized scaled
photographs, the authors decided that healing

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Volume 130, Number 6 • Platelet Concentrates and Wound Healing

Table 7. Literature Review*

No. of
Reference Participants Wound Type Platelet Concentrate Endpoint
Anitua et al., 20085 14 Chronic ulcers P-PRP (PRGF) Healed surface percentage
Spyridakis et al., 200931 52 Skin defects after pilonidal L-PRP Healing delay
excision†
Cervelli et al., 201132 22 Lower extremity traumas L-PRP plus hyaluronic Epithelialization delay†
acid
Cervelli et al., 200933 20 Lower extremity ulcers L-PRP plus adipocyte Epithelialization delay†
grafting
34
Chen et al., 2010 15 Lower extremity ulcers Platelet gel plus skin Skin graft survival rate†
graft
Kazakos et al., 200935 59 Acute lower leg trauma PRP Wound surface modification
Zumstein et al., 201238 26 Rotator cuff repair L-PRP Postoperative pain
Danielsen et al., 201036 51 Postoperative abdominal tissue P-PRP Healing tissue strength
in PTFE tube
Danielsen et al, 200837 21 Skin graft donor site and lower P-PRP Epithelialization delay†
extremity ulcers†
P-PRP, pure platelet-rich plasma; PRGF, plasma rich in growth factors; L-PRP, leukocyte- and platelet-rich plasma; PTFE, polytetrafluoroeth-
ylene.
*Trials evaluating the effect of other platelet concentrates. Comparison with our results could have been made if wound type, plate-
let concentrate, and endpoint were similar to our study’s parameters. Only the marked cells (†) of the table are comparable to our study’s
variables. No study though had all of the three parameters similar to our study’s parameters, and this makes comparison
difficult.

evaluation by the community nurse would have
been more applicable and more convenient for
the patients. The nurses had written instructions
concerning wound care and healing appreciation
to obtain standardized observations. Thus, heal-
ing day was appreciated in the same way for all of
the patients, giving conclusive results.
Leukocyte- and platelet-rich fibrin has a lim-
ited lifespan. The fibrin membrane remains stable
in the wound, with a peak of platelet growth factor
secretion variously reported on day 718,19or day
14,11,20,39 and it may last even until day 28.38 The
literature thus suggests that after a certain period
the fibrin ceases to be functional and the rate of
healing would then be similar to that of the con-
trol group. If the shorter period is confirmed, the
differences between the groups would be small in
the absence of several applications of leukocyte-
and platelet-rich fibrin. However, we wanted to
investigate the effects of a single application of
fibrin, which is both simpler and less expensive
than multiple applications.
We observed that wound dimensions were sig-
nificantly larger in the leukocyte- and platelet-rich
fibrin group. The mean width and length of the
operative wound on day 0 were 15.4 and 44.7 mm,
respectively, for the fibrin group; and 11.3 mm
and 37.0 mm, respectively, for the Vaselitulle
group. This may have affected our results on the
healing delay and biased our comparison al-
though, should that have been the case, it would
have been unfavorable for the fibrin group. It is
possible that the 5-day improvement in the rate of
healing observed in the fibrin group would have
been even greater had the wound dimensions
been similar.
The secondary endpoints may have lacked the
power to reach statistical significance. Given the
low initial visual analogue scale score for pain in
both groups and given the low bleeding and ex-
udate, it would have been difficult to show any
clinically relevant difference. Also, the sample size
may have been insufficient to detect such small
visual analogue scale differences. In addition, the
secondary endpoint evaluation by the investiga-
tors may be considered as subjective, making the
secondary endpoint results less conclusive but still
in coherence with the result of statistically proven
more rapid wound healing.
CONCLUSIONS
A single leukocyte- and platelet-rich fibrin ap-
plication in this wound model accelerated healing
by 5 days. Further randomized controlled clinical
trials are needed to study its applicability in other
wound types.
Georgiou A. Charalambos, M.D.
Plastic Reconstructive and Aesthetic Surgery Department
St. Roch University Hospital of Nice
5 Pierre Devoluy
0600 Nice, France
char.georgiou@gmail.com
ACKNOWLEDGMENTS
An academic grant from the French Ministry of
Health supported this study (Programme Hospitalier de

827e
 Plastic and Reconstructive Surgery • December 2012
Recherche Clinique régional-PHRC 2007). The sponsor
was solely responsible for funding and did not participate
in the study’s design, data collection, analysis and in-
terpretation, or in writing or in deciding to submit this
article for publication.
REFERENCES
1. Ousey K, Shorney RH. What are the quality indicators in
wound care? Wounds UK. 2009;5:53–55.
2. Eppley BL, Pietrzak WS, Blanton M. Platelet-rich plasma: A
review of biology and applications in plastic surgery. Plast
Reconstr Surg. 2006;118:147e–159e.
3. Hood AH, Hill AG, Reeder GD. Perioperative autologous
sequestration III: A new physiologic glue with wound healing
properties. Proc Am Acad Cardiovasc Perf. 1993;14:126–129.
4. Sánchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet-rich
therapies in the treatment of orthopaedic sport injuries.
Sports Med. 2009;39:345–354.
5. Anitua E, Aguirre JJ, Algorta J, Ayerdi E, Cabezas AI, Orive
G. Effectiveness of autologous preparation rich in growth
factors for the treatment of chronic cutaneous ulcers.
J Biomed Mater Res B Appl Biomater. 2008;84:415–421.
6. Marx RE. Platelet-rich plasma: Evidence to support its use.
J Oral Maxillofac Surg. 2004;62:489–496.
7. Wirz S, Dietrich M, Flanagan TC, et al. Influence of platelet-
derived growth factor-AB on tissue development in autolo-
gous platelet-rich plasma gels. Tissue Eng Part A 2011;17:
1891–1899.
8. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Clas-
sification of platelet concentrates: From pure platelet-rich
plasma (P-PRP) to leucocyte- and platelet-rich fibrin
(L-PRF). Trends Biotechnol. 2009;27:158–167.
9. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part I:
Technological concepts and evolution. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2006;101:e37–e44.
10. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part II:
Platelet-related biologic features. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2006;101:e45–e50.
11. Dohan Ehrenfest DM, Doglioli P, de Peppo GM, Del Corso
M, Charrier JB. Choukroun’s platelet-rich fibrin (PRF) stim-
ulates in vitro proliferation and differentiation of human
oral bone mesenchymal stem cell in a dose-dependent way.
Arch Oral Biol. 2010;55:185–194.
12. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part IV:
Clinical effects on tissue healing. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2006;101:e56–e60.
13. Thorat M, Pradeep AR, Pallavi B. Clinical effect of autolo-
gous platelet-rich fibrin in the treatment of intra-bony de-
fects: A controlled clinical trial. J Clin Periodontol. 2011;38:
925–932.
14. Dale O, Salo M. The Helsinki Declaration, research guide-
lines and regulations: Present and future editorial aspects.
Acta Anaesthesiol Scand. 1996;40:771–772.
15. McCash CR. The open palm technique in Dupuytren’s con-
tracture. Br J Plast Surg. 1964;17:271–280.
16. Choukroun JAF, Schoeffler C, Vervelle A. An opportunity in
perio-implantology: The PRF (in French). Implantodontie
2001;42:55–62.
17. Kang YH, Jeon SH, Park JY, et al. Platelet-rich fibrin is a
Bioscaffold and reservoir of growth factors for tissue regen-
eration. Tissue Eng Part A 2011;17:349–359.
828e
18. Chang IC, Tsai CH, Chang YC. Platelet-rich fibrin modulates
the expression of extracellular signal-regulated protein ki-
nase and osteoprotegerin in human osteoblasts. J Biomed
Mater Res Part A 2010;95:327–332.
19. Dohan Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino
G. Slow release of growth factors and thrombospondin-1 in
Choukroun’s platelet-rich fibrin (PRF): A gold standard to
achieve for all surgical platelet concentrates technologies.
Growth Factors 2009;27:63–69.
20. He L, Lin Y, Hu X, Zhang Y, Wu H. A comparative study of
platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) on
the effect of proliferation and differentiation of rat osteo-
blasts in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2009;108:707–713.
21. Mwaura B, Mahendran B, Hynes N, et al. The impact of
differential expression of extracellular matrix metallopro-
teinase inducer, matrix metalloproteinase-2, tissue inhibitor
of matrix metalloproteinase-2 and PDGF-AA on the chro-
nicity of venous leg ulcers. Eur J Vasc Endovasc Surg. 2006;
31:306–310.
22. Anitua E, Sánchez M, Orive G, Andı́a I. The potential impact
of the preparation rich in growth factors (PRGF) in different
medical fields. Biomaterials 2007;28:4551–4560.
23. Cieslik-Bielecka A, Gazdzik TS, Bielecki TM, Cieslik T. Why
the platelet-rich gel has antimicrobial activity? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2007;103:303–305; author
reply 305–306.
24. Moojen DJ, Everts PA, Schure RM, et al. Antimicrobial ac-
tivity of platelet-leukocyte gel against Staphylococcus aureus.
J Orthop Res. 2008;26:404–410.
25. El-Sharkawy H, Kantarci A, Deady J, et al. Platelet-rich plas-
ma: Growth factors and pro- and anti-inflammatory proper-
ties. J Periodontol. 2007;78:661–669.
26. Dohan Ehrenfest DM, Bielecki T, Jimbo R, et al. Do the fibrin
architecture and leukocyte content influence the growth
factor release of platelet concentrates? An evidence-based
answer comparing a pure platelet-rich plasma (P-PRP) gel
and a leukocyte- and platelet-rich fibrin (L-PRF). Curr Pharm
Biotechnol. 2012;13:1145–1152.
27. Werther K, Christensen IJ, Nielsen HJ. Determination of
vascular endothelial growth factor (VEGF) in circulating
blood: Significance of VEGF in various leucocytes and plate-
lets. Scand J Clin Lab Invest. 2002;62:343–350.
28. Bielecki T, Dohan Ehrenfest DM, Everts PA, Wiczkowski A.
The role of leukocytes from L-PRP/L-PRF in wound healing
and immune defense: New perspectives. Curr Pharm Biotech-
nol. 2012;13:1153–1162.
29. Foucher G, Cornil C, Lenoble E. Open palm technique for
Dupuytren’s disease: A five-year follow-up. Ann Chir Main
Memb Super. 1992;11:362–366.
30. Tubiana R, Michon J, Thomine JM. Scheme for the assess-
ment of deformities in Dupuytren’s disease. Surg Clin North
Am. 1968;48:979–984.
31. Spyridakis M, Christodoulidis G, Chatzitheofilou C, Syme-
onidis D, Tepetes K. The role of the platelet-rich plasma in
accelerating the wound-healing process and recovery in pa-
tients being operated for pilonidal sinus disease: Preliminary
results. World J Surg. 2009;33:1764–1769.
32. Cervelli V, Lucarini L, Spallone D, et al. Use of platelet-rich
plasma and hyaluronic acid in the loss of substance with bone
exposure. Adv Skin Wound Care 2011;24:176–181.
33. Cervelli V, Gentile P, Grimaldi M. Regenerative surgery: Use
of fat grafting combined with platelet-rich plasma for chronic
lower-extremity ulcers. Aesthetic Plast Surg. 2009;33:340–345.
Volume 130, Number 6 • Platelet Concentrates and Wound Healing
34. Chen TM, Tsai JC, Burnouf T. A novel technique com-
bining platelet gel, skin graft, and fibrin glue for healing
recalcitrant lower extremity ulcers. Dermatol Surg. 2010;
36:453–460.
35. Kazakos K, Lyras DN, Verettas D, Tilkeridis K, Tryfonidis M.
The use of autologous PRP gel as an aid in the management
of acute trauma wounds. Injury 2009;40:801–805.
36. Danielsen PL, Agren MS, Jorgensen LN. Platelet-rich fibrin
versus albumin in surgical wound repair: A randomized trial
with paired design. Ann Surg. 2010;251:825–831.
37. Danielsen P, Jørgensen B, Karlsmark T, Jorgensen LN, Agren
MS. Effect of topical autologous platelet-rich fibrin versus no
intervention on epithelialization of donor sites and meshed
split-thickness skin autografts: A randomized clinical trial.
Plast Reconstr Surg. 2008;122:1431–1440.
38. Zumstein MA, Berger S, Schober M, et al. Leukocyte- and
platelet-rich fibrin (L-PRF) for long-term delivery of
growth factor in rotator cuff repair: Review, preliminary
results and future directions. Curr Pharm Biotechnol. 2012;
13:1196–1206.
39. Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, Hippolyte
MP, Charrier JB. In vitro effects of Choukroun’s PRF (plate-
let-rich fibrin) on human gingival fibroblasts, dermal prek-
eratinocytes, preadipocytes, and maxillofacial osteoblasts in
primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2009;108:341–352.
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