25. Tissue Glues
Joseph Meyerson, Renato Saltz
PRINCIPLES OF THE PERFECT TISSUE ADHESIVE
■ High bonding strength
■ Ease of operative applications
■ Reproducible outcomes
■ Nontoxic to tissue
■ Affordable cost
FIBRIN SEALANT
HISTORY
■ Fibrin powder used as hemostat and sealant by Bergel1 in 1909
■ Described as an adhesive for skin grafts in 1940s2,3
■ Approved by FDA in 1998 for use as a hemostatic agent and as a tissue sealant in liquid form; fibrin sealant patch approved in 20104
• Artiss (Baxter) is the only fibrin sealant approved specifically for autologous skin grafting and flap adherence in rhytidectomy.
■ Fibrin sealant approved by the FDA as a hemostat, adhesive, and sealant
MECHANISM OF ACTION5
■ Fibrin clot forms from a polymerized fibrin compound resulting from the reaction of fibrinogen and thrombin.
• Thrombin cleaves larger subunits of fibrinogen, creating fibrin subunits, which in turn polymerize.
• Factor XIII and calcium cause cross-linking and formation of a stable fibrin clot.
■ Fibrin clot will degrade in approximately 10-14 days.
DELIVERY SYSTEM6,7,8
■ Delivery systems consist of two separate components of fibrin and thrombin that combine on exiting the device through a double-barrel syringe with a Y-connector.
• May be applied locally or aerosolized for larger surfaces
■ Commercially available products contain components from varied sources.
• Fibrinogen from human pooled plasma or a patient’s own plasma
• Thrombin of human or bovine origin
• Aprotinin (antifibrinolytic protein)
• Factor XIII and calcium (catalysts)
• Equine collagen and cellulose matrix available for fibrin patch design
PRICING9
■ Liquid form approximately $50/ml of fibrin sealant
■ Fibrin sealant patches range $600-$800/patch
NOTE: Prices for these products may vary based on contracting.
COMPLICATIONS10
■ Commercial preparations of fibrin sealants have risk of bloodborne pathogens (viral, prions).
■ Products with bovine components can cause disseminated coagulopathy.
■ Aprotinin-containing products can cause anaphylaxis, rash.
■ Air emboli can occur with pressurized applications.
■ Thick layers of fibrin allowed to polymerize before tissue apposition can inhibit wound healing and act as an antiadhesive.
APPLICATIONS
■ Conflicting studies exist for the outcomes of fibrin sealant used in cosmetic procedures.
■ Lower levels of thrombin (5 units/ml) allow the sealant to set at a slower rate, resulting in extended time for flap manipulation.
• Multiple studies show statistically significant decrease in drain output with fibrin sealant versus control.
• Varied reports in decreasing hematoma, edema, and ecchymosis formation.
• Randomized controlled, blinded trial compared one side of the face without fibrin sealant and the addition of fibrin sealant on the other. The fibrin sealant side reduced average drainage volumes (20 ml without fibrin glue versus 7.7 ml with fibrin glue, p <0.0001) without increasing the incidence of hematoma or seroma.
• Prospective, double-blind, randomized, controlled trial on the use of fibrin sealant in 20 consecutive patients undergoing facelifts by the same surgeon. Each patient was randomized for the use of fibrin sealant on either the right or the left side of the face with the contralateral side acting as the control. Total drainage was recorded on each side for 24 hours before drains were removed. The side treated with fibrin glue had a median drainage of 10 ml and the control side 30 ml (p <0.002).
• Prospective, nonblinded, randomized, controlled trial in 30 patients undergoing facelifts. Patients were their own controls and were randomized to having glue on one side of their face. Drainage on glued side was 7.5 ml less than unglued in 24 hour output, but not thought to be clinically significant (p <0.05).
SENIOR AUTHOR TIP: I have used tissue glues in all my facial rejuvenation procedures since 1991. They help to “seal” the space after SMAS treatment is completed. They appear to reduce swelling, bruising, and small seromas/hematomas.
■ Abdominoplasty14
• Fibrin sealants have been shown to lower rates of seroma postoperatively.
• One prospective study demonstrated fibrin sealant may be inferior to surgical drains or quilting.
► Forty-three patients were randomly placed into three groups during abdominoplasty and evaluated with ultrasound for evidence of seroma postoperatively. Group one, abdominoplasty with suction drains alone. Group two, abdominoplasty with quilting suture, and group three, abdominoplasty with fibrin sealant. Seroma formation was significantly lower in drain (13.9 ml) and quilting (16.1 ml) groups compared with the fibrin sealant (53.6 ml) group (p <0.05).
■ Blepharoplasty15
• Shown to be an acceptable alternative or adjunct to sutures for closure in upper blepharoplasty.
• When compared with standard suture techniques, the incidence of minor problems such as milia formation was lower, with the only complication of glue only technique was one wound separation in 16 patients. Endorses using fibrin glue and a minimal number of sutures for blepharoplasty patients.
■ Browlift16
• A retrospective study of endoscopic browlifts found that fixation with only fibrin sealant resulted in loss of brow elevation 3 months postoperatively.
• In 538 patients two different fixation methods were compared.
► Group one had fibrin glue and group two had polydioxanone sutures used as fixation.
► At 1 month postoperatively, each fixation technique remained equivocal and stable in regards to brow elevation.
► At 3 months postoperatively, there was a significant difference in brow elevation with a higher number of relapses in ptosis in the patients treated with only fibrin glue (p <0.01).
SENIOR AUTHOR TIP: The use of tissue glues after endoscopic midface suspension has decreased the postoperative swelling from 4 to 2 weeks, as well as the bruising and pain involved.
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