Aesthetic Plastic Surgery

, Volume 33, Issue 3, pp 336–339

Use of Tissue Sealants in Face-Lifts: A Metaanalysis

Authors

    • Department of Plastic, Reconstructive and Aesthetic SurgeryKandang Kerbau Women’s and Children’s Hospital
  • Luming Shi
    • Clinical Trials and Epidemiology Research UnitNational Medical Research Council, Ministry of Health
  • Miny Samuel
    • Clinical Trials and Epidemiology Research UnitNational Medical Research Council, Ministry of Health
  • Colin Song
    • Department of Plastic, Reconstructive and Aesthetic SurgerySingapore General Hospital
  • Vincent Kok-Leng Yeow
    • Department of Plastic, Reconstructive and Aesthetic SurgeryKandang Kerbau Women’s and Children’s Hospital
Original Article

DOI: 10.1007/s00266-008-9280-1

Cite this article as:
Por, Y., Shi, L., Samuel, M. et al. Aesth Plast Surg (2009) 33: 336. doi:10.1007/s00266-008-9280-1

Abstract

Background

This review sought to determine the efficacy of tissue sealants such as fibrin tissue adhesives and platelet-rich plasma in reducing postoperative drainage, ecchymosis, and edema after face-lift surgery.

Methods

The electronic databases MEDLINE (1966–May 2007) and EMBASE (1974–May 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for human studies, randomized controlled trials, controlled clinical trials, metaanalyses, and reviews of randomized controlled trials using the key words “fibrin tissue adhesive,” “tissue sealant,” “platelet-rich plasma,” “face-lift,” “rhytidoplasty,” “rhytidectomy,” and “facial plastic surgery.” The search yielded 10 articles, only 3 of which met our inclusion criteria. The three studies were within-patient comparisons (patients acted as their own controls).

Results

Although not statistically significant, the pooled results showed a strong trend toward reduction in postoperative drainage at 24 h and ecchymosis with the use of tissue sealants compared with the control arm of the study. No difference in outcomes was observed between the tissue sealant and control arms of the study in terms of postoperative edema measurement.

Conclusion

There was no statistically significant benefit from the use of tissue sealants in face-lift surgery. However, tissue sealants may be useful for patients at a high risk for hematoma and ecchymosis formation.

Keywords

Face-liftMetaanalysisRhytidoplastyTissue sealant

A major complication after face-lifting is hematoma formation, which has a reported incidence of 1.86–9% [1]. The risk of hematoma formation is due to the creation of a large raw surface under the skin flap. If the hematoma is not drained expediently, it may result in skin necrosis, with disastrous consequences.

Currently, there are two agents, namely, fibrin tissue adhesives and platelet-rich plasma, that not only provide hemostasis but also act as tissue sealants. Both agents contain fibrinogen, which is converted to fibrin by thrombin and calcium chloride. Fibrin tissue adhesives have a higher concentration of fibrinogen than platelet-rich plasma, and therefore have a higher adhesive strength [2]. However, as an additional benefit, platelet-rich plasma is autologous and has additional growth factors that may contribute to wound healing [3]. For the purpose of this study, the term “tissue sealants” is used to describe both fibrin tissue adhesives and platelet-rich plasma.

The use of tissue sealants is reported for various surgical procedures such as postparotidectomy wound management, postthyroidectomy wound management, spinal cord surgery, pulmonary lobectomy, breast surgery, axillary dissection, prostatectomy, total knee arthroplasty and liver resection. For face-lifts, the evidence for the use of tissue sealants has not been conclusively reported. At least one study found that fibrin glue had no effect of reducing hematomas requiring surgical evacuation in face-lifts [1]. Therefore, the authors conducted this metaanalysis to obtain evidence from the existing literature regarding the use of tissue sealants in face-lifts.

Materials and Methods

Only prospective randomized controlled trials were included in this review. The participants could be patients from all age groups undergoing face-lifts or rhytidoplasties. The intervention was application of a tissue sealant. The primary outcome measure was drainage from the wound bed after 24 h. The secondary outcome measures were postoperative ecchymosis and edema at 7–8 days.

A reduction in postoperative wound drainage is important because it greatly influences patient comfort, reduces complications, and hastens recovery. In addition, a reduction in postoperative ecchymosis is important because it reduces patient anxiety.

The electronic databases MEDLINE (1966–May 2007) and EMBASE (1974–May 2007), and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Under “intervention of interest,” the authors searched fibrin tissue adhesive, tissue sealant, and platelet-rich plasma. Under “types of surgery,” the authors searched face-lift, rhytidoplasty, rhytidectomy, and facial plastic surgery. The inclusion criteria limited the trials in the study to human studies, randomized controlled trials, controlled clinical trials, metaanalyses, and reviews of randomized controlled trials. This yielded 10 articles, only 3 of which met our inclusion criteria [46].

The studies by Marchac and Greensmith [4] and Oliver et al. [5] allowed measurement of wound bed drainage at 24 h, whereas the studies by Marchac and Greensmith [4] and Powell et al. [6] allowed the measurement of postoperative ecchymosis and edema 7–8 days after surgery (Tables 1 and 2). Powell et al. [6] made their observations an average of 7 days after surgery, whereas Marchac and Greensmith [4] made their observations 8 days after surgery.
Table 1

Randomized controlled trials investigating the efficacy of tissue sealants in patients with face-lifts

Author

Age (years)

No. of patients

Control

Procedure

Sealant

Volume (ml)

Outcome measures

Marchac and Greensmith [4]

42–72

30

Self

Vertical U incision, SMAS plication

Tisseel

Not mentioned

Drainage at 24 h, Ecchymosis, Edema

Oliver et al. [5]

44–70

20

Self

Subcutaneous, SMAS plication

Beriplast P

1

Drainage at 24 h

Powell et al. [6]

Not mentioned

8

Self

Deep-plane face-lift

Autologous platelet-rich Plasma

7–8

Ecchymosis, Edema

Table 2

Methodologic quality of trials

Author

Ethics approval

Sealant

Volume of sealant (ml)

Randomization

Blinding

Concealment of allocation

Intention- to-treat analysis

Loss to follow-up

Marchac et al. [4]

Yes

Tisseel

Not mentioned

Yes

Yes

Not mentioned

No

None

Oliver et al. [5]

Yes

Beriplast P

1

Yes

Yes

Yes

Yes

None

Powell et al. [6]

Yes

Autologous platelet-rich plasma

7–8

Yes

Yes

Not mentioned

Yes

None

The Forest plot was generated using the Cochrane Collaborator Software Review Manager 4.2.8. The random-effect model was used instead of the fixed-effect model because of the variations in the magnitude of the effect measurements. In the interpretation of the results for postoperative ecchymosis and edema, the numbers counted were for beneficial effect and no beneficial effect. The cases with equal results were counted as having no difference in effect.

Results

The Forest plot showed that for the primary outcome measure of wound drainage at 24 h, there was a strong trend toward reduction of wound drainage with the use of tissue sealants. However, the pooled analysis crossed the line of no effect, thus negating any statistical significance (p = 0.10) (Table 3).
Table 3

Postoperative drainage at 24 h: tissue sealant versus control, as expressed by weighted mean difference

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-008-9280-1/MediaObjects/266_2008_9280_Figa_HTML.gif

With regard to the secondary outcome measures, the Forest plot for postoperative ecchymosis at 7–8 days also showed a strong trend toward reduction of ecchymosis with the use of tissue sealants. However no statistical significance was observed because the pooled analysis had again crossed the line of no effect (p = 0.08) (Table 4). The Forest plot for postoperative edema at 7–8 days showed no difference in outcome between the use of tissue sealants and the control arm of the study (p = 0.66) (Table 5).
Table 4

Postoperative ecchymosis at 7–8 days: tissue sealant versus control, as expressed by weighted mean difference

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-008-9280-1/MediaObjects/266_2008_9280_Figb_HTML.gif

Table 5

Postoperative edema at 7–8 days: tissue sealant versus control, as expressed by weighted mean difference

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-008-9280-1/MediaObjects/266_2008_9280_Figc_HTML.gif

Discussion

Fibrin tissue adhesives are composed of two components. The first component contains fibrinogen and aprotinin, and the other contains thrombin and calcium chloride. Reconstitution of these two components results in a physiologic reaction, which mimics the final step of the coagulation cascade. Fibrinogen is converted to fibrin on the wound surface by the action of thrombin in the presence of calcium ions. Aprotinin then acts to inhibit clot lysis by endogenous plasmin.

Fibrin tissue adhesives have the advantage that they can be obtained off the shelf with relatively easy preparation. The use of fibrin glue also has disadvantages including disease transmission via human or animal blood products, added costs to the patient, prolonged surgical time, a false sense of security, idiopathic allergic reactions, and difficulty with evacuation of localized clots.

Platelet-rich plasma is formed by centrifugation of autologous whole blood, resulting in a concentration of platelets and a native concentration of fibrinogen [7]. The addition of thrombin and calcium chloride to platelet-rich plasma releases a cascade of growth factors from the platelet alpha granules and causes the formation of a clot.

The use of platelet-rich plasma has the advantage that the plasma is mainly autologous. The only risk of disease transmission is from the use of bovine thrombin. The main disadvantage of platelet-rich plasma is the need to process blood from the patient. This is time consuming and requires costly equipment as well as trained personnel.

This metaanalysis showed strong trends toward reduction of wound drainage and postoperative ecchymosis among patients who had used tissue sealants. This is the primary effect of tissue sealants, namely, formation of a clot, binding of the tissue planes together, and minimized fluid or hematoma collection. The result is reduction of both wound drainage and postoperative ecchymosis.

The results for postoperative edema were more equally balanced between the use of tissue sealants and the control arm of the study. Tissue edema is partly a result of surgical trauma and reduced vascularity of the affected tissues. The reason for the lack of reduced tissue edema in the tissue sealant group may be that the secondary effect of tissue sealants to improve neovascularization and thus reduce tissue edema may not be apparent at postoperative day 7 or 8.

In this metaanalysis, the authors found only three studies that fit the inclusion criteria. The small number of studies and patients may have contributed to a lack of statistical power and a failure to detect statistical significance. Needless to say, further studies with larger sample sizes are needed. However, the performance of a prospective, randomized controlled trial in cosmetic surgery is understandably fraught with difficulties. Therefore, it is important to pool such studies, no matter how small, to supplement the literature and improve our knowledge and management of these patients.

Although no statistically significant findings were derived from this metaanalysis, the authors conclude that, based on current evidence, it is safe to perform face-lifts using drains alone, with no adverse effect on the final cosmetic result. A recent study by Jones et al. [8] also found that the use of surgical drains alone in face-lifts was effective in reducing ecchymosis. The use of tissue sealants may be reserved for patients with a high risk for hematomas, for example, patients with agitation, hypertension, and coagulopathy, as well as male face-lift patients.

Copyright information

© Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2008