Platelet-Rich Plasma and Fibrin Sealants in Plastic Surgery: Clinical Applications and One Practice’s Experience

Key Points

Platelet products have been used intraoperatively both as a solution (platelet-rich plasma [PRP]) and as an autologous sealant (platelet-rich fibrin matrix).
We have had excellent outcomes using platelet-poor fibrin sealant then PRP during all open or endoscopic facial surgery including rhinoplasty with or without septoplasty, face and neck lift, minimal access cranial suspension short scar facelift, endoscopic brow lift, blepharoplasty, otoplasty, and laser resurfacing.
Our rates of hematoma and/or seroma as well as recovery time (return to socialization) are substantially less than anticipated. A growing body of literature supports these findings, though many studies have been underpowered.
In terms of autologous fat grafting, addition of PRP has yielded variable results, perhaps due to differences in PRP purity and preparation methodology.

Since learning of the availability of platelet-rich plasma (PRP) as an autologous fibrin sealant (platelet-rich fibrin sealant or platelet-rich fibrin matrix) in 2001, ¹ the senior author has used multiple PRP preparation systems. The concept of an autologous product that would both act as a sealant as well as promote wound healing was intriguing. Prior to 2001, this technology was known to oral and maxillofacial surgeons, otolaryngologists, and orthopedists but just being introduced into the plastic surgery literature. ²^, ³ The role of platelets in wound healing had been recognized for decades, but before the early 2000s, we were only familiar with using platelet concentrates to accelerate reepithelialization (where delay in wound healing had occurred in cases of lathyrism from the effects of medications used to treat rheumatoid arthritis). ⁴

In our practice, this product has been useful as a sealant for open surgical procedures and to accelerate the wound healing process. It is uncommonly used for body procedures such as mammoplasty and abdominoplasty since the volume required for such large surface areas makes it impractical. However, platelet products lend themselves quite well to facial procedures because of the smaller surface area, specifically rhinoplasty, facelifts, endoscopic brow lifts, blepharoplasty, otoplasty, and laser resurfacing. ⁵^, ⁶^, ⁷ These operations rely on perfect hemostasis for ideal aesthetic outcomes and therefore, it is critical to avoid the sequelae of postoperative bleeding. Even small collections of blood can result in fibrosis and deformities. In our practice, the routine utilization of PRP as an autologous fibrin sealant has fulfilled this promise by helping to reduce bleeding and speed recovery. Patients benefit from the reliable hemostasis and jumpstart in the healing process; in particular, facelift patients do not need surgical drains, and many enjoy a rapid return to society including work, school, and social life. This reduced recovery time makes facial rejuvenation and nasal reshaping procedures more palatable to our patients. Downtime for surgical recovery due to ecchymosis and swelling has always been a barrier to patients seeking these otherwise life-changing procedures. We have a long experience with the use of other medications and surgical instruments whose function is to reduce ecchymosis and swelling including desmopressin (DDAVP) as a hemostatic agent and ultrahigh-frequency power tools (Piezotome; Comeg Medical, Minneapolis, MN) for precision reshaping of bone and cartilage. ⁸^, ⁹^, ¹⁰ Minimizing recovery while optimizing outcomes may have a profound impact. So, all adjuncts to surgery such as PRP, that decrease downtime should be implemented.

We share our vast experience using platelet products intraoperatively followed by discussion of the evidence to date.

2.1 Methods and Materials

All patients undergoing an open or endoscopic facial surgery including rhinoplasty with or without septoplasty, endoscopic brow lift, face and neck lift, minimal access cranial suspension short scar facelift, blepharoplasty, otoplasty, and laser resurfacing were treated with platelet-poor fibrin sealant and then PRP following the manufacturer’s guidelines. The patients were screened for anticoagulant medications and supplements and discontinued from these starting two weeks prior to surgery. They were instructed to abstain from alcohol for 24 hours prior to the procedure. Untreated or undertreated hypertension was addressed by primary care physician prior to the operation. All patients on angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were switched to a β-blocker perioperatively to avoid angioedema. All patients underwent an autologous blood draw following strict Harvest protocol and strict sterile technique. Blood draw was usually at the time of intravenous catheter insertion utilizing a 20-gauge catheter. This was done before any intravenous medications were administered. When catheter extraction of the required aliquot became difficult due to vein collapse, then the blood was drawn in the operating room after the induction of general anesthesia when veins generally dilate. The collected volume depended on the need for a small Harvest kit (AdiPrep II system, Harvest Terumo BCT, Inc., Lakewood, CO) for rhinoplasty, blepharoplasty, otoplasty or periorbital laser resurfacing or large kit for facelift, endoscopic brow lift, or full-face laser resurfacing, based on necessary body surface area. The blood draw was done with the requisite 30-cc or 60-cc syringe, respectively and mixed with a citrate anticoagulant to prevent clot formation. Preparation followed the manufacturer instructions. Briefly, blood was transferred to a sterile double barrel receptacle for underwent two centrifuge spin cycles—the first for 11 minutes and second for 3 minutes. We extracted platelet-poor plasma (PPP) from the top layer of the centrifuge specimen and injected into a sterile cup on the sterile operating field. A small Harvest generally yields 10 cc of PPP and the larger Harvest 20 cc of PPP. Next, the bottom of PRP portion was extracted and injected into a separate sterile cup on the field. With a small Harvest, we expect approximately 3 cc of PRP and a large, 6 cc of PRP. Topical thrombin (of bovine origin) was placed in a third cup on the sterile field and mixed with calcium gluconate provided the necessary catalyst to initiate the fibrin cascade. The two products are delivered via a double barrel syringe (a 10 mL for the plasma either PPP or PRP, and a 1 mL for the thrombin calcium solution). The spray emitted through the double-barrel syringes was delivered via one of two applicator tip options: one with two small openings (for wide field use such as facelifts and laser resurfacing) and the other with a catheter tip (for narrow surgical fields such as endoscopic procedures, rhinoplasty, or septoplasty use). A fibrin clot forms, when the substances contact the open wound. In all cases, a fine mist was sprayed over the entire field with PPP fibrin sealant then followed by gentle compression of the tissues over the wound bed for 5 minutes. We expected a sealant not an adhesive effect, observing a tacky consistency. Finally, a fine mist of the PRP fibrin sealant was sprayed over the wound bed, paying attention to good coverage of the incision sites, to promote wound healing.

Of note, we have since switched preparatory systems and in fact, have multiple in our office. The number of FDA-cleared class II devices has increased in number since implementation of our off-label protocol. We have achieved good results using various protocols, although have not compared them head-to-head. Discussion of preparatory protocols and systems is beyond the scope of this section and addressed more fully in Chapter 1.

The 58 consecutive face and neck lift patients including the short scar and full incisional techniques, and 64 consecutive rhinoplasties with or without septoplasty that were completed between January 2017 and June 2018 were included in the analysis. We did not include endoscopic brow lift or resurfacing procedures in this analysis (see Chapter 3 for laser resurfacing). There were no exclusion criteria other than the suitability of the patient to undergo such facial procedures. The gender distribution for facelift was 3 male and 55 female, and for rhinoplasty, 15 male and 49 female. The majority of rhinoplasties included septoplasty and turbinate reduction with radiofrequency devices. In the cases of face and neck lift ( ▶ Table 2.1 and ▶ Table 2.2), hematoma, infection, skin compromise, ecchymosis, and time considered adequate for social reintegration were taken from the patient’s record. In the cases of rhinoplasty ( ▶ Table 2.3 and ▶ Table 2.4), hematoma (septal or subcutaneous), ecchymosis, and suitability for return to socialization are recorded as extracted from the patient’s record.