Use of Tissue Sealants in Face-Lifts: A Metaanalysis
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- Por, Y., Shi, L., Samuel, M. et al. Aesth Plast Surg (2009) 33: 336. doi:10.1007/s00266-008-9280-1
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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.
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).
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.
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.
A major complication after face-lifting is hematoma formation, which has a reported incidence of 1.86–9% . 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 . However, as an additional benefit, platelet-rich plasma is autologous and has additional growth factors that may contribute to wound healing . 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 . 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 [4–6].
Randomized controlled trials investigating the efficacy of tissue sealants in patients with face-lifts
No. of patients
Marchac and Greensmith 
Vertical U incision, SMAS plication
Drainage at 24 h, Ecchymosis, Edema
Oliver et al. 
Subcutaneous, SMAS plication
Drainage at 24 h
Powell et al. 
Autologous platelet-rich Plasma
Methodologic quality of trials
Volume of sealant (ml)
Concealment of allocation
Intention- to-treat analysis
Loss to follow-up
Marchac et al. 
Oliver et al. 
Powell et al. 
Autologous platelet-rich plasma
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.
Postoperative ecchymosis at 7–8 days: tissue sealant versus control, as expressed by weighted mean difference
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 . 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.  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.