New Surgical Approach to Lichen Sclerosus of the Vulva: The Role of Adipose-Derived Mesenchymal Cells and Platelet-Rich Plasma in Tissue Regeneration

Abstract

Sir: Lichen sclerosus is a chronic inflammatory disease usually affecting the anogenital area. Tissue sclerosis and atrophy are present. Women are affected more than men. The etiopathogenesis is unknown, and the severe consequences are functional and psychological. Symptoms vary according to the stage of the disease. In the early phase, sclerosis involves the clitoris area; in the advanced phase, it extends to the labia minora, the labia majora, and the fork. The vulva changes shape with subsequent reduction of vulvar introit and painful ulcers appear. Topical corticosteroids are the standard treatment but require continuous administration, and associated complications are evident. Surgical therapy consists of vulvectomy, cryosurgery, and laser ablation.1 However, these procedures add scars to damaged tissues and have high recurrence rates. The aim of this article is to present a new regenerative approach that removes symptoms and reduces atrophy and sclerosis. This method is based on grafting of adipose-derived stem cells and injection of platelet-rich plasma. Fifteen female patients with a histologic diagnosis of lichen sclerosus were treated. Age ranged from 27 to 62 years. All patients had previously undergone steroid therapy, without any significant improvement. A blood sample of 50 ml was drawn from the patient. The blood was centrifuged at 1000 rpm for 6 minutes to obtain platelet-poor plasma. After a second centrifugation (3000 rpm for 12 minutes), a platelet-rich plasma was obtained. Approximately 5 ml of platelet-rich plasma was obtained (centrifuge diameter, 52.5 cm). After sedation and local infiltration by Klein solution, liposuction was carried out from a donor region with a 3-mm cannula and a 10-ml syringe. The lipoaspirate was washed with saline solution, decanted, and injected through a 14-gauge needle in the damaged area (range, 15 ml fat). Finally, 5 ml of platelet-rich plasma was injected into the same areas in the intradermal-intramucosal, subdermal, and submucosal compartments. Before injection, platelet-rich plasma was added with 0.5 ml of calcium chloride for platelet degranulation. All patients left the hospital a few hours after surgery. No adverse events were observed in this series of patients. All patients had moderate pain in the treated areas for 10 days after surgery. Fifteen days after intervention, symptoms improved: itching and burning disappeared within 1 month. Vulvar skin and mucosa appeared more elastic and soft, with a normal color. Four months after surgery, all patients reported total disappearance of pain and symptoms, and the anatomical features of the vulva were quite normal. All patients regained sexual activity. Patients with severe fibrosis and atrophy underwent the procedure one or two times more, after 3 months, with satisfactory and stable results. Follow-up ranged from 6 to 24 months (Fig. 1).Fig. 1.: (Above) Preoperative view of the initial stage of lichen sclerosus in a 52-year-old woman. It is evident by a marked sclerosis of the clitoris area. (Below) Postoperative appearance after two treatments with an interval of 3 months. Complete tissue restoration of the sclerotic area is evident.An innovative approach for patients affected by lichen sclerosus was described, in which the treatment was aimed at repairing tissue dystrophy. Traditional reconstructive surgery (e.g., grafts, flaps) should have had a high risk of complications. Therefore, a regenerative procedure was performed. Examples of skin regeneration after radiotherapy damage by lipofilling have been reported.2 Moreover, other “regenerative” techniques using platelet-rich plasma in dentistry and maxillofacial and orthopedic surgery are described. Growth factors released by platelets have an important role in inflammation reduction, angiogenesis stimulation, and collagen III synthesis.3,4 The procedure can be considered effective as therapy for lichen sclerosus disease. ACKNOWLEDGMENT The authors express their thanks to Barbara Cavazza for invaluable advice and comments regarding the article. Francesco Casabona, M.D. Virginia Priano, M.D. Department of Plastic and Reconstructive Surgery Valerio Vallerino, M.D. Department of Obstetrics and Gynecology Angela Cogliandro, M.D. Department of Transfusion Unit Giorgio Lavagnino, M.D. Department of Plastic and Reconstructive Surgery Villa Scassi Hospital Genoa, Italy