Experience with Fibrin Glue in Rhytidectomy

A Systematic Review: Fibrin Glue in Drainless Rhytidoplasty

The following questions guided the study: Can the use of fibrin glue in drainless rhytidoplasty reduce hematoma prevalence, seroma prevalence increase patient satisfaction or decrease the length of hospital in the adult population compared with standard treatment? The following inclusion and exclusion criteria apply: The procedure performed was rhytidoplasty for both groups. Participants were limited to adults who did not have any other procedure performed during the study. The intervention consisted of the use of fibrin glue without drains compared to the control group, in which drains and/or pressure dressing were applied. Databases: clinicaltrials.gov, MEDLINE, COCHRANE, mRCT, PubMed, Google Scholar, Scopus, Embase, VHL, GHL were searched on 03/25/2023 by 2 different investigators. The Cochrane Risk of Bias Tool 2.0 was used. Five studies were included with a total number of 1277 participants (2554 face sides). The cumulative hematoma rate was OR 0.47 (95% CI 0.26-0.84) in favor of using fibrin glue. Insufficient data were available to assess seroma rate, patient satisfaction, and length of hospital stay. The risk of study bias was judged to be low and moderate. The certainty for the use of fibrin sealant versus drainage is high and the importance of outcomes is rated as important in the GRADEpro GDT tool. Fibrin glue use is more beneficial comparing to drainage in patients undergoing rhytidectomy in terms of hematoma prevalence. This study was registered in PROSPERO (CRD42023421475).Level of Evidence I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?

BACKGROUND

In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members' face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances.

METHODS

A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test.

RESULTS

A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication.

CONCLUSIONS

The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.

Methods for Minimizing Bleeding in Facelift Surgery: An Evidence-based Review

INTRODUCTION

Bleeding and hematoma remain leading causes of postoperative complications and unsatisfactory patient outcomes in facelift surgery. Several methods have been implemented, and continue to be developed, to minimize bleeding in facelift surgery. These methods include perioperative blood pressure management, compression dressings, drains, tissue sealants, wetting solution infiltrate, and tranexamic acid.

METHODS

An evidence-based review of methods used to minimize bleeding in facelift surgery was conducted using the PubMed database according to PRISMA guidelines. Included studies were evaluated for the effects of implemented methods on bleeding outcomes in facelift surgery. Recommendations for each method evaluated were determined based on the amount, level, and heterogeneity of included studies.

RESULTS

Thirty-six studies were included in the evidence-based review. Effective strategies to reduce the time to hemostasis, postoperative drainage volume, and hematoma rate included perioperative blood pressure management, tissue sealants, and tranexamic acid. While the use of drains or wetting solution infiltrate did not demonstrate to significantly influence bleeding outcome measures, these methods may provide other advantages to facelift surgery. Compression dressings have not demonstrated a significant effect on facelift outcome measures.

CONCLUSIONS

Perioperative medical management of blood pressure, tissue sealants, and tranexamic acid are most effective in facilitating hemostasis and preventing postoperative hematoma in facelift surgery.

Perioperative Approach to Reducing Hematoma during Rhytidectomy: What Does the Evidence Show?

BACKGROUND

Postoperative hematoma remains the most common complication in rhytidectomy, prompting surgeons to use a multitude of adjunctive measures to prevent its occurrence. The goal of this systematic review was to determine which of these measures are supported by strong evidence, and to highlight those that remain unsubstantiated and require further investigation.

METHODS

A systematic search was performed of the PubMed and Embase databases for English literature from 1975 to March of 2020 containing designated keywords, and focusing specifically on adjunctive measures aimed at preventing hematoma in rhytidectomy. The resultant articles were then systematically screened according to predefined inclusion and exclusion criteria to determine eligibility for inclusion in the study.

RESULTS

The keyword search yielded a total of 2391 articles. Title and abstract screening resulted in 103 articles that were eligible for full-text review. Ultimately, 48 articles met final inclusion criteria. The articles were categorized into their particular mode of intervention: fibrin tissue sealants, perioperative medications (anesthetics, antihypertensives, miscellaneous medications), and intraoperative maneuvers (hemostatic agents, preinfiltration, intraoperative maneuvers, and drains). Nine studies were indexed as evidence Level II and 24 as evidence Level III. The remainder of studies constituted Level IV evidence.

CONCLUSIONS

Adjunctive interventions have been borne out of necessity in efforts to reduce postoperative hematoma after rhytidectomy. Although many of these interventions have promising results, the current literature supports the senior author's (R.J.R.) experience that an evidence-based, multimodal approach is ideal to minimize the rates of hematoma after rhytidectomy.

Prospective Study Assessing the Effect of Local Infiltration of Tranexamic Acid on Facelift Bleeding

BACKGROUND

Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery.

OBJECTIVES

The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage.

METHODS

This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded.

RESULTS

The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications.

CONCLUSIONS

TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

LEVEL OF EVIDENCE: 2

Conservative Neck Rejuvenation

In the field of facial rejuvenation, among the recurrent topics, one of the most discussed is the return to less invasive techniques. Lower face rejuvenation is best achieved acting on the platysma muscle. Many techniques are used and usually include platysma section, redundancy reduction, and redraping. Platysma plication is also used especially in secondary cases because of the increased risk of nerve injury due to possible anatomical damage caused by previous operations. A technique that preserves the deep planes based on a new plication method is proposed (conservative neck rejuvenation). In this technique, the dissection plane is only subcutaneous to reduce the risk of nerve injuries. An effective neck contouring is possible using a simpler technique with very good results and a lower rate of morbidity.

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

Quilting Sutures in Rhytidectomy: A Systematic Review of the Literature

BACKGROUND

Different technical variations exist for the utilization of quilting sutures (QS) in rhytidectomy. No systematic review or meta-analysis of the studies describing the use of QS in facelifts has been published to date to the authors' knowledge.

OBJECTIVES

The objective of this study was to summarize all the published data regarding the utilization of QS in rhytidectomy, compare QS techniques, and evaluate their effect on postoperative complications.

METHODS

On April 1, 2019, a systematic search of the Medline, Embase, and Cochrane databases was conducted. All the studies describing the usage of QS in facelifts were included in this review. Studies reporting hematoma rate in a QS group and a control group were included in the meta-analysis part of this study.

RESULTS

The initial search of the databases yielded 93 results. Four trials were included in the systematic review and 2 were included in the meta-analysis. The total number of included patients with QS was 527. Two studies employed internal QS and the remaining studies utilized external QS. The meta-analysis found a lower rate of hematoma in the QS group (relative risk, 0.02; 95% confidence interval = 0.00-0.13; P < 0.0001).

CONCLUSIONS

QS can be applied either internally or externally and are very effective in reducing hematomas after facelifts. QS could be a great asset in facelifts but should be utilized with caution because additional work is needed to confirm their safety and efficacy.

LEVEL OF EVIDENCE: 2

A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques

BACKGROUND

Sub-superficial musculo-aponeurotic system (SMAS) rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, compared with less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection.

OBJECTIVES

The authors sought to aggregate and summarize data on complications among different SMAS facelift techniques.

METHODS

A broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total 183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rates of temporary nerve injury and were the only techniques to show a statistically significant difference compared with SMAS plication (odds ratio [OR] = 2.71 and 2.22, respectively, P < 0.05). Risk of permanent injury did not differ among techniques. An increase in major hematoma was found for the deep plane (1.22%, OR = 1.67, P < 0.05) and SMAS imbrication (1.92%, OR = 2.65, P < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR = 2.29, P < 0.01).

CONCLUSIONS

There are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Technique should be selected based on quality of results and not the complication profile.

LEVEL OF EVIDENCE: 2

Efficacy and Safety of Artiss Fibrin Tissue Sealant Use in Rhytidectomy: A Review of 120 Cases

Hematoma formation has persisted as the most common complication in rhytidectomy. The objective of this study is to determine the efficacy and safety of Artiss (Baxter) for use in rhytidectomies. In addition, we determine the use of fibrin tissue sealants by facial plastic surgeons. In this retrospective chart review, 120 patients in a single private practice were identified who underwent a rhytidectomy from August 2013 to January 2015 by a single facial plastic surgeon. The last 60 rhytidectomies performed with Tisseel (Baxter) were compared with the first 60 rhytidectomies performed with Artiss.

All perioperative or postoperative complications were identified and recorded, focusing on the incidence of hematoma. In addition, a six-question survey was created and sent to all members of the American Academy of Facial Plastic and Reconstructive Surgery. Results of the survey were recorded and analyzed for trends or patterns in the data. In total, 120 patients were assessed. In the Tisseel group, two complications of fluid collection requiring needle aspiration were recorded. No other complications were found. In the Artiss group, 10 complications were recorded, including 9 fluid collections requiring needle aspiration and 1 hematoma. In total, 179 members of the American Academy of Facial Plastic and Reconstructive Surgery completed the six-question survey. Of all respondents, 61 (34%) use tissue sealants for rhytidectomies, whereas 118 (66%) do not. Artiss is efficacious and safe for use in rhytidectomies. Its use obviates the need for surgical drains, and complications are minimal and similar in rate to the use of Tisseel.

Fibrin glue as a protective tool for microanastomoses in limb reconstructive surgery

Aim: Fibrin glue becomes a more and more routinely used tool for stabilization of microanastomoses and nerve repair. This paper summarizes the technical properties and advantages of its use in a wide variety of microsurgical contexts, and includes an exemplary limb reconstructive case.

Patients and methods: A total of 131 patients who had undergone elective and emergency microsurgery mainly of the limbs were retrospectively analyzed, as was the use of free flaps.

Results: The use of fibrin glue allows for proper positioning of anastomoses and repaired nerves. No torsion of the pedicle could be seen. The flap survival rated >94%. The fibrin glue could stay in place in >99%. In the rare case of revision, the fibrin glue could easily be removed without damaging the region of the microanastomosis.

Conclusion: Fibrin glue should not be used to repair insufficient, i.e., leaking anastomoses, but it does protect the site of anastomosis from tissue and fluid pressure. It prevents the pedickle from torsion and its use facilitates relocation of the microanastomoses in cases of revision surgery.

Evaluation of Face Lift Skin Perfusion and Epinephrine Effect Using Laser Fluorescence Imaging

Supplemental Digital Content is available in the text.

Face lift dissections are believed to compromise skin flap circulation, possibly leading to wound healing complications. To reduce blood loss, plastic surgeons commonly inject a solution of local anesthetic that contains epinephrine. However, the effect of surgery on skin perfusion and the degree of vasoconstriction caused by the epinephrine have not been quantitated. Little information is available to guide the selection of epinephrine concentration.

Fibrin tissue adhesive for face- and necklift

INTRODUCTION

Although available for decades, fibrin-based tissue adhesives (FTAs) have enjoyed only variable popularity in aesthetic surgery since their introduction in the 1980s. Whilst benefits in facelift surgery have been reported for a range of measures, including expanding haematoma, oedema and ecchymosis, irrefutable evidence has not yet been forthcoming. We instigated a prospective study to test the hypothesis that an underappreciated property of FTA, namely its ability to distribute tension, would reduce complications and revision due to early relapse.

PATIENTS AND METHODS

The study group comprised 100 consecutive facelifts with FTA. The comparative group comprised the immediate preceding 100 patients who underwent similar interventions, but with drains instead of FTA. All surgery was undertaken by the senior author using standard techniques and statistical analysis employing Fisher's exact test.

RESULTS

The groups were comparable in age, gender distribution, co-morbidity and declared cigarette smoking. Complications were recorded in 24 patients with significantly more in the comparative group (p = 0.048), particularly hypertrophic scarring (p = 0.029). Although there appeared a greater prevalence of revision and cutaneous necrosis in the comparative group, these did not reach statistical significance.

DISCUSSION

To the many published benefits, we can add that FTA can reduce complications, particularly hypertrophic scarring, and it now forms an important part of our facelift practice.

A systematic examination of the effect of tissue glues on rhytidectomy complications

BACKGROUND

Fibrin glue has widespread use in multiple fields of surgery. There have been numerous studies on the use of fibrin glue in facelifts, with no consensus regarding differences in outcomes.

OBJECTIVES

This study compared the risk of hematoma, seroma, and the 24-hour drainage volume in all published prospective controlled trials.

METHODS

A MEDLINE search of English-language articles on fibrin glue and rhytidectomy published up to July 2013 yielded 49 citations. After screening, we examined 7 relevant controlled trials. The DerSimonian and Laird random-effects model was used to perform the meta-analysis.

RESULTS

Seven controlled trials measuring the outcomes of fibrin glue in facelifts were used to estimate the pooled relative risk of complications and confidence intervals. Hematoma formation was four times less likely with the use of fibrin glue (relative risk 0.25, P = .002). There was no significant reduction in seroma formation (relative risk 0.56, P = .19). There was not enough data to properly measure 24-hour drainage and ecchymoses.

CONCLUSIONS

This analysis suggests that fibrin glue reduces the rates of hematoma formation, but does not significantly reduce the rates of seroma development.

LEVEL OF EVIDENCE

3 Therapeutic.

Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients

BACKGROUND

Hematoma is the most common postoperative complication of rhytidoplasty, resulting in higher morbidity and longer recovery. Quilting suture for closure of the undermined area in abdominoplasty avoids the occurrence of seroma. Based on this principle and with the objective of reducing the number of patients with hematomas in rhytidoplasty, a similar surgical tactic was developed in which a hemostatic net is created with a running transfixing suture of 5-0 nylon encompassing the skin and the superficial musculoaponeurotic system-platysma.

METHODS

The study enrolled 525 consecutive patients who underwent rhytidoplasty between July 2009 and February 2013. The first 120 patients (group A) were evaluated retrospectively and considered control subjects. The remaining 405 patients (group B) had application of the described tactic, with data collected prospectively. The occurrence of hematoma, ischemia, and necrosis was observed during the first 72 h after surgery.

RESULTS

Control group A included 17 patients with hematoma (14.2 %) during the first 72 h, whereas no patient in group B experienced such a complication (p < 0.001). The surgical tactic did not significantly increase the occurrence of ischemia. This complication was experienced by 11 patients in group A (9.2 %) and 26 patients in group B (6.4 %) (p = 0.408). The tactic also did not change the incidence of necrosis, which was present in three group A patients (2.5 %) and six group B patients (1.5 %) (p = 0.723).

CONCLUSION

The hemostatic net is an efficient and safe method for preventing early hematomas in rhytidoplasties. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of commercial fibrin sealants in facelift surgery: a prospective study

Background

The aim of this study was to compare the effects of two types of fibrin glue in patients undergoing facelift surgery.

Methods

A prospective, controlled “right-left side” study was carried out in 20 patients. The two fibrin sealants used were Quixil® and Tissucol®. The two sealants were used at the same time, ie, one on one side of the face and the other on the contralateral side. Comparisons were made with regard to rates of hematoma and seroma, degree of induration, edema, ecchymosis, pain levels, and patient satisfaction.

Results

The results were almost equivalent. The only exception was a significant (40 mL) hematoma in a patient treated with Quixil. Bleeding was most likely due to a sudden rise in blood pressure during the immediate postoperative period. However, it must be emphasized that, while Tissucol actually seals the undermined area, thus virtually eliminating the dead space, Quixil acts differently, in that its effectiveness in preventing hematoma is linked mainly to its hemostatic effect.

Conclusion

The two fibrin sealants used were nearly identical with regard to patient safety and quality of the result. Nevertheless, it is noted that, while Tissucol has both hemostatic and “gluing” effects, Quixil is mainly effective in securing hemostasis.

The effect of fibrin sealant on the prevention of seroma formation after postbariatric abdominoplasty

BACKGROUND

Seroma formation is one of the most common complications following abdominoplasty. Fibrin sealant/glue has shown mixed results in seroma prevention when used in a variety of procedures. Limited information is available on its effectiveness during postbariatric abdominoplasty.

METHODS

A retrospective chart analysis of 65 consecutive patients who underwent postbariatric abdominoplasty over a course of 16 months by a single surgeon was performed. Two sequential groups either receiving or not receiving fibrin sealant treatment were defined. Seroma formation and initial 24 h drain output volumes were recorded.

RESULTS

Three patients in group 1 (9.1%) receiving fibrin sealant developed seroma. Twelve patients in group 2 (28.1%) not receiving fibrin sealant developed seroma; this was statistically significant (P=0.006). Twenty-four hour drain output was also statistically different, with higher initial output in the fibrin sealant group (222.2 mL versus 140.0 mL; P=0.047).

CONCLUSION

Fibrin sealant was a useful adjunct during surgical wound closure and significantly decreased seroma formation in patients undergoing postbariatric abdominoplasty.

Efficacy and safety of fibrin sealant for tissue adherence in facial rhytidectomy

The purpose of this review is to clarify the present use of fibrin sealant in rhyditectomy procedures and help maximize the appropriate and safe application of this material. A set of terms and definitions for hemostats, sealants, and adhesives based on group, category, and class will be employed to highlight the specific capabilities of fibrin sealant. Fibrin sealant has now emerged as an example of maximizing the usefulness of a surgical agent and is the only product with Food and Drug Administration approval in all three groupings: hemostats; sealants; and adhesives. A variety of manufacturers’ fibrin sealant products are available including multiple liquids and one patch. A single liquid product is now specifically indicated for skin flap adherence during rhytidectomy. The unique characteristic of this particular two component fibrin sealant adhesive agent is its slower polymerization rate as a result of a low thrombin concentration which when combined with fibrinogen permits adequate time for manipulation of flaps and tissues prior to final fixation. In addition to its flap adherence and potential space elimination capability, fibrin sealant is also an excellent blood clotting agent and can seal tissues to prevent lymphatic leak or serous fluid accumulation. Thus, it is almost ideally suited to reduce the occurrence of fluid accumulation, hematomas, ecchymoses, and swelling, as well as to possibly eliminate the need for drains following rhytidectomy. A literature review of fibrin sealant in rhytidectomy is included to help define the current state of its clinical use. The author’s recommendations for the best use of this material during facial procedures are also provided.

The asian face lift

The face-lift procedure (rhytidectomy) is increasingly popular in Asia. There is extensive literature on different techniques in Western patients. Cultural and anthropomorphologic differences between Asian and Caucasians require the adaptation of current techniques to obtain a satisfactory outcome for both the patient and the surgeon. This article therefore attempts to define important differences between Asians and Caucasians in terms of signs of facial aging, perception of beauty, and surgical goals. Our face-lift technique, a modified deep-plane face lift for Asians, is detailed and cases are presented.

Prevention of acute hematoma after face-lifts

Acute hematoma remains one of the most frequently encountered complications after face-lift surgery. Several risk factors inherent to the patient and omission of certain intraoperative regimens are considered to cause hematoma. Significant risk factors include high blood pressure and male gender. Possible intraoperative regimens for the prevention of hematoma include tumescence infiltration without adrenaline, clotting of raw surfaces with fibrin glue, usage of drains, and application of compression bandages. However, little attention has been paid to postoperative measures. To examine whether different regimens in the postoperative phase can influence the incidence of hematoma, all face-lift patients who underwent surgery by a single surgeon in two different clinics (n = 376) with two different postoperative regimens were evaluated over the course of 3 years. In group 1 (n = 308), all postoperative medication was administered on request including medication for pain control, blood pressure stabilization, and prevention of nausea and vomiting as well as postoperative restlessness and agitation. In group 2 (n = 68), this medication was administered prophylactically at the end of the operation before extubation. The hematoma rate was 7% in group 1 and 0% in group 2. This study showed that the prophylactic use of medications (e.g., analgesics, antihypertonics, antiemetics, and sedatives) during the postoperative phase is superior to making drugs available to patients on request and can decrease the occurrence of acute hematoma in face-lift patients.

Use of oxidized regenerated cellulose to stop bleeding after a facelift procedure

A 52-year-old woman came to our department about correcting a severe soft-tissue laxity after a weight loss of 67 kg. We performed a deep-plane face lift under sedation with local anesthesia. Three hours after the operation the patient had significant and diffuse bleeding, which was controlled by a local hemostatic agent made of oxidized regenerated cellulose (Tabotamp). In the weeks after the operation no local pain or skin damage was observed. We believe that oxidized regenerated cellulose could be a good ancillary therapy for controlling local bleeding associated with this kind of surgery.