Platelet-Rich Plasma and Tadalafil Pretreatment Enhance Survival of Random-Pattern Skin Flaps in Rats

Skin flap necrosis remains a major challenge in reconstructive surgery, particularly in random-pattern flaps with vulnerable distal territories. Platelet-rich plasma (PRP) promotes angiogenesis, whereas tadalafil enhances microcirculatory perfusion. This study evaluated whether preoperative PRP and tadalafil, alone or in combination, improve flap survival. Forty male Wistar albino rats were randomized to Sham, PRP, Tadalafil, and Combination groups. Flap survival was assessed on postoperative day 7 using digital planimetry and radionuclide scintigraphy. Histopathological assessment of distal, demarcation, and proximal regions included microvessel counts and semi-quantitative scoring of inflammation, edema, and necrosis. Tissue total antioxidant status (TAS), total oxidant status (TOS), and malondialdehyde (MDA) were measured, and oxidative stress index (OSI) was calculated. The Combination group had the highest flap survival (73.52 ± 6.6% by planimetry; 80.92 ± 8.6% by scintigraphy), whereas the Sham group had the lowest values (54.55 ± 8.6% and 58.08 ± 10.1%, respectively; p < 0.001 for both). Flap survival was greater in all treatment groups than in Sham. Microvessel density differed significantly among groups, and Sham showed the highest MDA, TOS, and OSI values and the lowest TAS. All treatment groups had higher TAS and lower TOS, MDA, and OSI than Sham ( p < 0.05), with the most favorable numerical profile in the Combination group. Preoperative PRP and tadalafil, alone or combined, improved random-pattern flap survival and were associated with enhanced neovascularization and reduced oxidative stress. The combination produced the greatest overall effect, supporting further investigation in flaps at high ischemic risk.