Surgical Adhesives in Facial Plastic Surgery

Transcription

1 Surgical Adhesives in Facial Plastic Surgery Dean M. Toriumi, Victor K. Chung, Quintin M. Cappelle University of Illinois at Chicago Chicago, IL Supplement to Toriumi DM, Chung VK, Cappelle QM. Surgical adhesives in facial plastic surgery. Otolaryngologic Clinics, Volume 49, Issue Elsevier Inc. All rights reserved.

2 Why is bleeding a problem in facial plastic surgery? Skin flap injury from cautery Extended operative time Delayed wound healing Poor aesthetic outcome Return to operating room

3 Categories of Surgical Tissue Adhesives Cyanoacrylates Fibrin tissue adhesives

4 Cyanoacrylates Superficial wound closure No hemostatic property, only a tissue adhesive Elicit foreign body reaction when placed subdermally Longer chains derivatives demonstrate decreased toxicity E.g. Dermabond (Ethicon, Somerville, NJ)

5 Fibrin Tissue Adhesives Mechanism of action occurs on the coagulation cascade, replicating the body s natural hemostasis pathway Conversion of fibrinogen to fibrin initiates clot formation Fibrin Tissue Adhesives are composed of 2 components that activate when mixed together

6 Coagulation Pathway Extrinsic and Intrinsic Pathways give way to the Common Pathway The last step in the common pathway is the conversion of fibrinogen to fibrin Fibrinogen in the plasma is converted to fibrin in the presence of thrombin and calcium chloride Factor XIII catalyzes fibrin molecules to cross-link to form a clot

7 Fibrin Tissue Adhesive Components Component 1 Fibrinogen, calcium chloride, Factor XIII Component 2 Thrombin and anti-fibrinolytic agent Component 1 Component 2 Fibrinogen Factor XIII Calcium Chloride Anti-fibrinolytic Thrombin Fibrin Sub-units Stable Fibrin Clot

8 Optimal Concentrations of Thrombin Thrombin concentration is proportional to the rate of polymerization High Thrombin concentration = rapid polymerization and hemostasis >500 U/mL Low thrombin concentration = slower polymerization and time for flap manipulation U/mL

9 Methods of Application Single Barrel Syringe Less uniform mixing Cumbersome Double Barrel syringe Clogging issues Gas-Pressurized Spray Requires pressurized air source Increased expense A B

10 Autologous Fibrin Tissue Adhesives Patient s own blood, autologous Collected pre-operatively No risk of disease transmission or immune reaction Centrifugation isolates the platelet-rich plasma layer Fibrinogen collected at a natural concentration Combined with pre-made mixture of thrombincalcium chloride Low risk of factor V cross-reactivity with bovine thrombin Selphyl device (Aesthetic Factors, LLC, Princeton, NJ)

11 Homologous Fibrin Tissue Adhesives Pooled donors, homologous Greater concentration of fibrinogen compared to plateletrich plasma Identical substrates of fibrinogen, thrombin, calcium chloride, Factor XIII Theoretical risks associated with homologous products (transmission of HIV and hepatitis) E.g. Tisseel and Artiss (Baxter Healthcare Corp., Deerfield, IL); Evicel (formerly Crosseel) (Omrix Biopharmaceuticals, Israel)

12 Risk of Viral Transmission from Homologous Products 1 reported case of B19 parvovirus transmission Risk estimated at 1:500,000 No reported cases of HIV, Hepatitis B, or Hepatitis C Risk estimated at < 1x10 15

13 What are the proposed benefits of fibrin tissue adhesives in facial plastic surgery? Improved hemostasis Expedited operating time Decreased edema Decreased ecchymosis Expedited postoperative recovery

14 FDA Off-label Use Fibrin combined with thrombin since 1944 FDA approval in 1998 Artiss (Baxter Healthcare Corp., Deerfield, IL) Adhere autologous skin grafts to surgically prepared wound beds resulting from burns in adult and pediatric populations Tisseel (Baxter Healthcare Corp., Deerfield, IL): Prevent leakage from colonic anastomoses, adjunct to hemostasis in adults and pediatric patients undergoing surgery Evicel (formerly Crosseel) (Omrix Biopharmaceuticals, Israel) Adjunct to hemostasis in patients undergoing liver surgery

15 A Applications in B Facial Plastic and Reconstructive Surgery Historic use 1944 first application Grafts & Flaps Obliterates dead space Promotes hemostasis C Decreases seroma formation Aids in neovascularization of graft or flap

16 Optimal Application Thickness Higher skin graft survival with thin application of fibrin sealant (vs. thicker application) Similar survival between thin application group and the control Decreased survival with thicker application versus the control Fibrinogen concentration did not affect skin graft survival Critical for grafts, but less important for well-vascularized flaps Thinner layer FTA Thicker FTA

17 Fibrin Tissue Adhesive Use in Facial Plastic Surgery: Rhytidectomy Randomized, prospective, blinded trials trend toward reduced drainage from indwelling suction drains and no effect on hematoma Retrospective (large) reduced hematoma rate in fibrin sealant group 3.4% vs 0.4%; p = 0.01 Sequential trials with unilaterally treated face: reduced both drainage and hematoma Fibrin glue reduced drainage but there was no difference in hematoma rates

18 Fibrin Tissue Adhesive Use in Facial Plastic Surgery: Rhytidectomy Technique: Lower thrombin concentration Skin flaps are designed and tailored Fixation sutures are placed, but not tied Pressurized spray application Skin flap is positioned Sutures are tied Pressure applied No drain placement Courtesy of Baxter; Deerfield, IL; with permission.

19 Fibrin Tissue Adhesive Use in Facial Plastic Surgery: Endoscopic Forehead Lift Technique Subperiosteal dissection Release of arcus marginalis Division of procerus and corrugator muscles Temporal dissection and lateral suture fixation Fixation with suture and fibrin tissue adhesive Fixation sutures are placed but not tied 2mL of homologous fibrin tissue adhesive along orbital rim and on divided muscles Normal thrombin concentration 15 cm malleable double-barrel applicator tip Fixation sutures are tied Pressure to glabella 5-10 minutes Courtesy of Baxter; Deerfield, IL; with permission.

20 Fibrin Tissue Adhesive Use in Facial Plastic Surgery: Selecting Cases Recommended for use in case by case basis Excess intraoperative bleeding Augmenting traditional fixation No supported role in rhinoplasty