The Use of Becaplermin as a Surgical Alternative
Some soft tissue defects present problems due to size, location, or the presence of underlying disease processes. Others can be challenging from a patient perspective, e.g., lack of available resources or noncompliance. In these cases, the risks and complications of surgical reconstruction must be balanced against the potential problems associated with lengthy or suboptimal secondary healing. In this series of difficult-to-manage wounds, the exogenous growth factor, becaplermin, facilitated closure and avoided the need for immobilization, complex surgery, and prolonged hospitalization. We believe that becaplermin therapy can play a valuable role in wound healing and should be considered in the treatment of certain difficult-to-manage wounds.
Successful evaluation and treatment of soft tissue injuries require a broad understanding of anatomy as well as familiarity with the wide spectrum of available treatment options. The mechanism of injury is important, as it helps to delineate the nature and extent of tissue loss and functional limitations. The primary goals of reconstructive surgery are restoration of form and function. Once a wound has been characterized with respect to size, location, and exposed vital structures, the reconstructive ladder -- a method-based algorithm emphasizing the selection of an operative technique based on wound complexity -- can be used to optimize wound closure.
Some soft tissue defects present problems due to size, location, or the presence of underlying disease processes. Others can be challenging from a patient perspective, e.g., lack of available resources or noncompliance. In these cases, the risks and complications of surgical reconstruction must be balanced against the potential problems associated with lengthy or suboptimal secondary healing. Over the past decade, several growth factors have been recognized for their beneficial effects on wound healing. Platelet-derived growth factor (PDGF) promotes the chemotactic recruitment and proliferation of key cells involved in the wound repair process. Recombinant human platelet-derived growth factor-BB (rhPDGF-BB; becaplermin) has biological activity similar to that of endogenous PDGF. Becaplermin has been shown to accelerate wound healing and increase the incidence of complete healing of chronic wounds in clinical studies. Becaplermin is the only growth factor approved by the Food and Drug Administration (FDA), and it is indicated for the treatment of lower-extremity, diabetic, neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. Growth factors bind to cell membrane receptors and initiate chemotaxis, mitosis, angiogenesis, and fibroblast proliferation. This physiologic activity is not diabetic specific and can be observed in nonmetabolically altered tissue. While FDA approval for becaplermin was obtained comparing wound healing rates in diabetic patients, there is no legal contraindication to prescribing becaplermin in nondiabetic patients. This off-label use is left to the clinician's medical judgement in treating each patient's specific problem.
The efficacy and safety of becaplermin for the treatment of these chronic ulcers has raised the possibility of its use in other difficult-to-manage, full-thickness wounds. We present a series of cases in which becaplermin was used to promote wound closure in patients with surgical challenges.
Abstract
Some soft tissue defects present problems due to size, location, or the presence of underlying disease processes. Others can be challenging from a patient perspective, e.g., lack of available resources or noncompliance. In these cases, the risks and complications of surgical reconstruction must be balanced against the potential problems associated with lengthy or suboptimal secondary healing. In this series of difficult-to-manage wounds, the exogenous growth factor, becaplermin, facilitated closure and avoided the need for immobilization, complex surgery, and prolonged hospitalization. We believe that becaplermin therapy can play a valuable role in wound healing and should be considered in the treatment of certain difficult-to-manage wounds.
Introduction
Successful evaluation and treatment of soft tissue injuries require a broad understanding of anatomy as well as familiarity with the wide spectrum of available treatment options. The mechanism of injury is important, as it helps to delineate the nature and extent of tissue loss and functional limitations. The primary goals of reconstructive surgery are restoration of form and function. Once a wound has been characterized with respect to size, location, and exposed vital structures, the reconstructive ladder -- a method-based algorithm emphasizing the selection of an operative technique based on wound complexity -- can be used to optimize wound closure.
Some soft tissue defects present problems due to size, location, or the presence of underlying disease processes. Others can be challenging from a patient perspective, e.g., lack of available resources or noncompliance. In these cases, the risks and complications of surgical reconstruction must be balanced against the potential problems associated with lengthy or suboptimal secondary healing. Over the past decade, several growth factors have been recognized for their beneficial effects on wound healing. Platelet-derived growth factor (PDGF) promotes the chemotactic recruitment and proliferation of key cells involved in the wound repair process. Recombinant human platelet-derived growth factor-BB (rhPDGF-BB; becaplermin) has biological activity similar to that of endogenous PDGF. Becaplermin has been shown to accelerate wound healing and increase the incidence of complete healing of chronic wounds in clinical studies. Becaplermin is the only growth factor approved by the Food and Drug Administration (FDA), and it is indicated for the treatment of lower-extremity, diabetic, neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. Growth factors bind to cell membrane receptors and initiate chemotaxis, mitosis, angiogenesis, and fibroblast proliferation. This physiologic activity is not diabetic specific and can be observed in nonmetabolically altered tissue. While FDA approval for becaplermin was obtained comparing wound healing rates in diabetic patients, there is no legal contraindication to prescribing becaplermin in nondiabetic patients. This off-label use is left to the clinician's medical judgement in treating each patient's specific problem.
The efficacy and safety of becaplermin for the treatment of these chronic ulcers has raised the possibility of its use in other difficult-to-manage, full-thickness wounds. We present a series of cases in which becaplermin was used to promote wound closure in patients with surgical challenges.
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