In facial plastic surgery, attaining hemostasis may require adjuncts to traditional surgical techniques. Fibrin tissue adhesives have broad applications in surgery and are particularly useful when addressing the soft tissue encountered in facial plastic surgery. Beyond hemostasis, tissue adhesion and enhanced wound healing are reported benefits associated with a decrease in operating time, necessity for drains and pressure dressings, and incidence of wound healing complications. These products are clinically accessible to most physicians who perform facial plastic surgery, including skin grafts, flaps, rhytidectomy, and endoscopic forehead lift.
Key learning points
At the end of this article, the reader will:
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Know when surgical adhesives are useful in facial plastic procedures.
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Be able to identify which step in the coagulation cascade fibrin tissue adhesives replicate.
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Know the potential risks of homologous fibrin tissue adhesives.
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Know which factors influence the efficacy of fibrin tissue adhesives.
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Be able to identify the indications for fibrin tissue adhesives in facial plastic surgery.
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Know the advantages and disadvantages of the different methods of application.
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Know the key steps for application of fibrin tissue adhesives in facial plastic procedures.
Introduction
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Skin flap injury from cautery
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Extended operating time
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Delayed wound healing
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Poor aesthetic outcome
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Return to operating room
Surgical bleeding should be anticipated and controlled in facial plastic surgery. Excessive bleeding and accumulation of blood can inhibit optimal healing, resulting in poor outcomes. Aesthetic surgery patients are concerned with prolonged downtime secondary to postoperative edema and ecchymosis. Surgeons typically limit electrocautery of superficial tissues, as it might injure the skin flap. Gaining hemostasis without electrocautery may extend operating time. Accumulation of postoperative bleeding may necessitate an emergent return to the operating room. In facial plastic surgery, surgical adhesives can be used to improve hemostasis and outcomes.
Introduction
- •
Skin flap injury from cautery
- •
Extended operating time
- •
Delayed wound healing
- •
Poor aesthetic outcome
- •
Return to operating room
Surgical bleeding should be anticipated and controlled in facial plastic surgery. Excessive bleeding and accumulation of blood can inhibit optimal healing, resulting in poor outcomes. Aesthetic surgery patients are concerned with prolonged downtime secondary to postoperative edema and ecchymosis. Surgeons typically limit electrocautery of superficial tissues, as it might injure the skin flap. Gaining hemostasis without electrocautery may extend operating time. Accumulation of postoperative bleeding may necessitate an emergent return to the operating room. In facial plastic surgery, surgical adhesives can be used to improve hemostasis and outcomes.
Surgical tissue adhesives
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Cyanoacrylates
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Fibrin tissue adhesives
When discussing surgical adhesives, both categories, cyanoacrylates and fibrin tissue adhesives, are frequently grouped together and considered the same product; however, the inherent properties of each provide important distinctions for their appropriate use. It should be clear that they have separate indications that do not overlap in application.
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Superficial wound closure
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No hemostatic property, only a tissue adhesive
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Elicit foreign body reaction when placed subdermally
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Longer-chain derivatives have decreased toxicity
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For example, Dermabond (Ethicon, Somerville, NJ)
During the development of cyanoacrylates, it was recognized that although they bonded and sealed tissue well, early cyanoacrylates generated a long-lasting inflammatory reaction within the body. By increasing the chain length of the molecule, the tissue reactivity decreased. These longer chain lengths can now be tolerated on the epidermis, but foreign body reactions still occur when cyanoacrylates are deposited below the dermis. Furthermore, this category of surgical adhesive has no hemostatic properties, limiting its application to superficial wound closure in facial plastic surgery ( Fig. 1 ).
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Mechanism of action occurs on the coagulation cascade, replicating the body’s natural hemostasis pathway
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Conversion of fibrinogen to fibrin initiates clot formation
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Fibrin tissue adhesives are composed of 2 components that activate when mixed together
Fibrin tissue adhesives, however, do have hemostatic properties. The body has an excellent mechanism to achieve blood clot formation. Blood clot formation occurs through the coagulation cascade of clotting factors within the blood plasma. The final result of that pathway is the conversion of the inactive fibrinogen to the active fibrin, which is one of the main components of clots. The 2 components of fibrin tissue adhesives take advantage of this physiology. To understand fibrin tissue adhesives’ mechanisms of action, an understanding of the body’s natural coagulation cascade must be reviewed.
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Extrinsic and intrinsic pathways give way to the common pathway
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The last step in the common pathway is the conversion of fibrinogen to fibrin
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Fibrinogen in the plasma is converted to fibrin in the presence of thrombin and calcium chloride
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Factor XIII catalyzes fibrin molecules to cross-link to form a clot
As seen in Fig. 2 , the extrinsic and intrinsic pathways converge into the common pathway. Fibrinogen is circulating within the plasma at baseline. When fibrinogen is in the presence of thrombin and calcium chloride, either endogenously or exogenously, it is converted to fibrin. Fibrin tissue adhesives take advantage of this natural pathway by supplying the coenzymes/factors necessary to complete the final steps of native coagulation. By activating a natural process, fibrin tissue adhesives artificially induce cross-linking and clot formation.
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Component 1
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Fibrinogen, calcium chloride, factor XIII
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Component 2
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Thrombin and antifibrinolytic agent
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Fibrin tissue adhesives contain exactly what is needed in clot formation. The catalysts (thrombin, calcium chloride, and factor XIII) convert the substrate (fibrinogen) into its stable product (cross-linked fibrin). In reactions, the substrate and catalysts are stored as separate components to prevent preemptive interaction. Fibrinogen must be kept segregated from thrombin until the time hemostasis is desired. These 2 components are ideally mixed at the time of application. In addition to thrombin, component 2 may contain an antifibrinolytic agent to slow fibrin clot degradation ( Fig. 3 ).
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Thrombin concentration is proportional to the rate of polymerization
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High thrombin concentration = rapid polymerization and hemostasis
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Greater than 500 U/mL
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Low thrombin concentration = slower polymerization and time for flap manipulation
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10 to 100 U/mL
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One of the customizable variables in fibrin tissue adhesives is the thrombin concentration. As the concentration of thrombin increases, the rate of polymerization and fibrin clot formation increases. In the role of hemostatic agent or sealant, high thrombin concentration (500 U/mL or greater) and rapid clotting are desired. When the surgeon needs time to position a skin graft or skin flap after applying the fibrin adhesive, a low thrombin concentration (10–100 U/mL) and slower rate of polymerization are more appropriate.
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Single-barrel syringe
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Less uniform mixing
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Cumbersome
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Double-barrel syringe
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Clogging issues
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Gas-pressurized spray
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Requires pressurized air source
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Increased expense
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Another variable is how the product is applied to the tissues. Of the available fibrin tissue delivery systems, sequential delivery of components 1 and 2 from 2 single-barrel syringes is the simplest. Less uniform mixing of the components and clumsy handling of multiple syringes limit this technique. A double-barrel syringe, such as Duploject (Immuno AG, Vienna, Austria), improves uniform mixing; however, early mixing and stasis result in clogging of the applicator needle. The aerosol spray device in Fig. 4 uses a pressurized gas stream at 5 to 10 L/min to maximally mix and evenly distribute the fibrin tissue adhesive. With a pressure-assisted system, the surgeon can achieve efficient mixing and, as a result, maximal strength of the glue with minimal volume ( Fig. 4 ).
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Patient’s own blood, autologous
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Collected preoperatively
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No risk of disease transmission or immune reaction
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Centrifugation isolates the platelet-rich plasma layer
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Fibrinogen collected at a natural concentration
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Combined with premade mixture of thrombin-calcium chloride
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Low risk of factor V cross-reactivity with bovine thrombin
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Selphyl device (Aesthetic Factors, LLC, Princeton, NJ)
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