Blepharoplasty Incisions With Autologous Fibrin Glue Closure of
Mark A.
Mandel, MD
\s=b\ Autologous fibrin glue was prepared from individual patients and used as a surgical adhesive. Sixteen patients undergoing elective eyelid operations were studied. The fibrinogen was prepared from autologous blood by a cryoprecipitate technique. When mixed with commercially available thrombin, a fibrin clot develops with sufficient adhesive strength that the need for extensive suturing is obviated. Complications were few, and due to technical factors in the initial cases, all patients were followed up for at least 1 year. Problems associated with suture closure of wounds (eg, cysts, granulomas, milia) were not seen. The fibrin glue not only sealed the wound but also acted as a hemostatic agent. The autologous preparation is superior to commercial products since it avoids the problem of transfusion\x=req-\ transmitted disease. The fibrin glue and minimal suture technique is an alternative to eyelid incision closure and may be useful in many other types of operative procedures.
PATIENTS AND METHODS
Sixteen patients underwent blepharo¬ plasty closures with the autologous glue technique. All of these operations were performed in conjunction with other major procedures. Blood was collected from each patient and ñbrinogen isolated using a cryoprecipitate technique (Corus Laborato¬ ries, Costa Mesa, Calif).12 The fibrinogen was frozen and the red blood cells preserved using standard techniques.3 At the time of surgery, the fibrinogen was thawed and brought to 37°C. Equal amounts of fibrin¬ ogen and commercially prepared thrombin (Parke-Davis, Morris Plains, NJ) were drawn up in separate syringes with a com¬ mon delivery tube (Fig 1). This method en¬ abled simultaneous application of both the fibrinogen and thrombin to the wounds with the formation of a thin layer of instant clot. The development of autologous fibrin
one
factors are not necessary in this case for clot formation; the event sequence is seen in Fig 2. The presence of factor XIII and cal¬ cium chloride causes cross netting of the fi¬ brin alpha chain, resulting in polymeriza¬ tion and a fibrin clot with strong bonding power. Fibrinolysis inhibitors, such as aprotinin, can be added to either component to prevent clot degradation. REPORT OF A CASE
A 70-year-old white woman had progres¬ sive wrinkling of her eyelids, face, and neck. Blepharoplasty and rhytidectomy were per¬ formed. The fibrinogen-thrombin mixture was applied to the eyelid suture lines. The preoperative, intraoperative, and postoper¬ ative views are seen in Fig 3. No problems were encountered during the postoperative
period.
Fig 1.—Syringe and spray applicator systems used in wound closure. The syringe is useful for eyelids while the spray is best for wider areas such as faces and abdomens.
(Arch Ophthalmol. 1990;108:842-844)
"D lepharoplasty is
glue is identical to the final normal coagu¬ lation pathway." Platelets and most other
of the most
plastic surgical opera¬ tions. It can be performed either alone common
in combination with other aesthetic and/or reconstructive procedures. The current investigation is concerned with wound closure in blepharoplasty using autologous fibrin glue and a min¬ imal number of sutures. or
Accepted for publication March 22, 1990. Dr Mandel is in private practice in Los Angeles, Calif. Presented at the Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, Calif, January 21, 1990. Reprint requests to Century City Medical Plaza, 2080 Century Park E, Suite 401, Los Angeles, CA 90067-2007 (Dr Mandel).
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/20/2015
RESULTS
complications associated with 16 patients whose eyelid incisions have been closed with only a few sutures and fibrin glue are reviewed in the Table. All of the patients have now been fol¬ The
lowed up for at least 1 year. Milia, su¬ ture cysts, granulomas, and other problems associated with suture clo¬ sure of wounds were not seen. One pa¬ tient developed a wound separation in the immediate postoperative period,
necessitating reclosure. In addition, it was noted that a tincture of benzoin dissolved the autologous glue, preclud¬ ing its use to enhance small tape (Steri-Strip, 3M, St Paul, Minn) adher¬ ence.
All of the patients in this study were in excellent health. Red blood cell re¬ placement was necessary due to losses from other operations performed at the same time. These included reduc¬ tion mammoplasty, abdominoplasty,
Fig 2.—Clotting sequence. The use of fibrinogen and thrombin initiates the final phases of clot¬ ting. Rapid polymerization of the fibrin occurs.
and liposuctioning. None of these pa¬ tients had autologous blood drawn spe¬ cifically for the purpose of having their eyelid incisions closed. There were no complications from the autologous do¬ nation procedure.1 COMMENT
The complication rate from eyelid closure using standard techniques is low.5 Patients may complain about the development of suture cysts, granulo¬ mas, or poor-quality scars. The tech¬ nique utilized prior to availability of fibrin glue included a subcuticular pullout suture for upper eyelid approx¬ imation with the lateral aspect rein¬ forced with a continuous skin suture.6 In the lower eyelid a fine running ny¬ lon suture was used. Other than tech¬ nical errors, many of the known com¬ plications are due to the use of suture material. To avoid such problems, cyanoacrylate glue has been recently recommended as a means to close the incisions.7 Variants of this glue have been available for over 2 decades for of Autologous Fibrin Glue in 16 Patients With
Complications
Blepharoplasty Wound Milia
separation
Suture cysts Granulomas Scar revision
Fig 3.—Top left, Elderly patient undergoing blepharoplasty. The preoperative view shows considerable wrinkling. Top right, The operative view shows the glue being applied. Bottom left, At 4 days, the thin fibrin clot is still seen. Bottom right, The well-healed wound at 1 year is noted.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/20/2015
1
0 0 0 0
wound
closure; however, the cyanoacrylates have not been approved by the Food and Drug Administration (Washington, DC) for human use in
the United States.8 Advocates of the cyanoacrylate eyelid wound closure state that the glue simply peels off and that complications are minimal. The incidence of hypersensitivity and longterm problems for the cyanoacrylate glue products in humans are not known at this time. Autologous fibrin glue is an alterna¬ tive method to close wounds. This ap¬ plication is simple, but care has to be taken since polymerization and devel¬ opment of significant bonding does not occur for several minutes.9 The autol¬ ogous glue, however, goes on to form a firm seal that has sufficient adhesive strength to keep the blepharoplasty incisions closed. The complications noted here were the initial technical ones that occurred from clot dissolu¬ tion by the application of tincture of benzoin. Long-term complications in¬ cluding suture cysts, granulomas, and poor-quality scars were not noted. First described over 70 years ago, tissue glue was rediscovered by Euro¬ pean investigators 20 years ago.1011 A study by Brück12 showed its usefulness in face-lift surgery. Commercially available pooled glue has also been useful in a variety of other surgical procedures, with over 700 reports in the world literature. This product is not available in the United States due to the risk of transfusion-transmitted diseases. A much safer autologous product, however, can be easily pre¬ pared from the individual patient at most hospital blood banks or by com¬ mercial hématologie services. The au¬ tologous preparation eliminates the risk of acquired immunodeficiency syndrome and other transfusiontransmitted infections.
Numerous studies indicate that
au¬
tologous fibrin glue can decrease com¬ plications due to bleeding, shorten the length of operations, and expedite healing.13"" The fibrin glue sets up rap¬ idly, adheres well to wounds, and has strong adhesive properties. Mixing fi¬ brinogen and thrombin initiates the second phase of coagulation with the formation of a fibrin network having considerable bonding power.2 A human dura experimental model was used to compare the strengths of autologous
preparations.9 Al¬ though initially the commercial glue was stronger, by 30 minutes the bond¬ ing power of the autologous glue was much greater. This strength was suf¬ ficient to keep wounds closed even un¬ and commercial
der tension.1819 The current clinical study confirms the adhesive properties of autologous fibrin with only minimal sutures needed to maintain wound co-
aptation.
In select cases, fibrin glue can be used as an alternative technique to close blepharoplasty wounds. The au¬ tologous preparation is superior to the commercial ones since it eliminates the risk of transfusion-transmitted disease. Since fibrin glue is not only adhesive, but also hemostatic, its use is now being extended to other proce¬ dures to determine if problems such as blood loss, hematoma formation, and healing difficulties can be altered in a
positive manner.
References 1. Mandel MA. Autotransfusions in elective
plastic surgical procedures. Plast Reconstr Surg. 1986;77:767-771.
Siedentop KH, Harris DM, Sanchez B. Autologous fibrin tissue adhesive. Laryngoscope. 2.
1985;95:1074-1076. 3. Dresdale A, Rose EA, Jeevanandam V, et al. Preparation of fibrin glue from single donor fresh frozen plasma. Surgery. 1985;97:750-755. 4. Kram HB, Nathan RC, Stafford FJ, Fleming
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/20/2015
AW, Shoemaker WZ. Fibrin glue achieves hemo-
stasis in patients with coagulation disorders. Arch Surg. 1989;124:385-387. 5. Nesi FA, Katzen LB, LiVecchi JT. Complications of blepharoplasty. In: Smith BC, Della Rocca RC, Nesi FA, Lisman R, eds. Ophthalmic Plastic and Reconstructive Surgery. St Louis, Mo: CV Mosby Co; 1987:732. 6. Rees TD. Blepharoplasty: surgical procedures in aesthetic plastic surgery. In: Aesthetic Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1980:470. 7. Kamer FM, Joseph JH. Histoacryl: its use in aesthetic facial plastic surgery. Arch Otolaryngol Head Neck Surg. 1989;115:193-197. 8. Mandel MA. Isolation of mouse lymphocytes for immunologic studies by thoracic duct cannulation. Proc Soc Exp Biol Med. 1967;126:521-524. 9. Siedentop KH, Harris DM, Sanchez B. Autologous fibrin tissue adhesive: factors influenc-
ing bonding
733. 10.
power.
Laryngoscope. 1988;98:731\x=req-\
Grey EG. Fibrin as a hemostatic in cranial Surg Gynecol Obstet. 1915;21:452.
surgery.
11. Matras H. Fibrin sealant in maxillofacial surgery: a review of the past 12 years. Facial Plast
Surg. 1985;2:297-313.
12. Bruck HG. Fibrin tissue adhesion and its in rhytidectomy: a pilot study. Aesthetic Plast
use
Surg. 1982;6:197-202. 13. Dresdale A, Bowman FO Jr, Malm JR, et al. Hemostatic effectiveness of fibrin glue derived from single donor fresh frozen plasma. Ann Thorac Surg. 1985;40:385-387. 14. Spotnitz WD, Dalton MS, Baker JW, Nolan SP. Reduction of perioperative hemorrhage by anterior mediastinal spray application of fibrin glue during cardiac operations. Ann Thorac Surg. 1987;44:529-531. 15. Rousou J, Levitsky S, Gonzalez-Lavin L, et al. Randomized clinical trial of fibrin sealant in
patients undergoing resternotomy or reoperation after cardiac operations: a multicenter study. J Thorac Cardiovasc Surg. 1989;97:194-203. 16. Moretz WH Jr, Shea JJ Jr, Emmett JR, Shea JJ III. A simple autologous fibrinogen glue for otologic surgery. Otolaryngol Head Neck Surg. 1986;95:122-124. 17. Stuart JD, Kenney JG, Lettieri J, Spotnitz W, Baker J. Application of single-donor fibrin glue to burns. J Burn Care Rehabil. 1988;9:619-622.
18. Henrick A, Gaster RN, Silverstone PJ. Or-
ganic tissue glue in closure of cataract incisions. J Cataract Refract Surg. 1987;13:551-553. 19. Steube D, Hamm KD, Pothe H, Schreiber D, Beer R. Fibrin glue on the Cohn I fraction basis in repairing cerebral and dura defects: an experimental study on rats. Folia Haematol (Leipz). 1988;115:213-217.
Mark A.
Mandel, MD
\s=b\ Autologous fibrin glue was prepared from individual patients and used as a surgical adhesive. Sixteen patients undergoing elective eyelid operations were studied. The fibrinogen was prepared from autologous blood by a cryoprecipitate technique. When mixed with commercially available thrombin, a fibrin clot develops with sufficient adhesive strength that the need for extensive suturing is obviated. Complications were few, and due to technical factors in the initial cases, all patients were followed up for at least 1 year. Problems associated with suture closure of wounds (eg, cysts, granulomas, milia) were not seen. The fibrin glue not only sealed the wound but also acted as a hemostatic agent. The autologous preparation is superior to commercial products since it avoids the problem of transfusion\x=req-\ transmitted disease. The fibrin glue and minimal suture technique is an alternative to eyelid incision closure and may be useful in many other types of operative procedures.
PATIENTS AND METHODS
Sixteen patients underwent blepharo¬ plasty closures with the autologous glue technique. All of these operations were performed in conjunction with other major procedures. Blood was collected from each patient and ñbrinogen isolated using a cryoprecipitate technique (Corus Laborato¬ ries, Costa Mesa, Calif).12 The fibrinogen was frozen and the red blood cells preserved using standard techniques.3 At the time of surgery, the fibrinogen was thawed and brought to 37°C. Equal amounts of fibrin¬ ogen and commercially prepared thrombin (Parke-Davis, Morris Plains, NJ) were drawn up in separate syringes with a com¬ mon delivery tube (Fig 1). This method en¬ abled simultaneous application of both the fibrinogen and thrombin to the wounds with the formation of a thin layer of instant clot. The development of autologous fibrin
one
factors are not necessary in this case for clot formation; the event sequence is seen in Fig 2. The presence of factor XIII and cal¬ cium chloride causes cross netting of the fi¬ brin alpha chain, resulting in polymeriza¬ tion and a fibrin clot with strong bonding power. Fibrinolysis inhibitors, such as aprotinin, can be added to either component to prevent clot degradation. REPORT OF A CASE
A 70-year-old white woman had progres¬ sive wrinkling of her eyelids, face, and neck. Blepharoplasty and rhytidectomy were per¬ formed. The fibrinogen-thrombin mixture was applied to the eyelid suture lines. The preoperative, intraoperative, and postoper¬ ative views are seen in Fig 3. No problems were encountered during the postoperative
period.
Fig 1.—Syringe and spray applicator systems used in wound closure. The syringe is useful for eyelids while the spray is best for wider areas such as faces and abdomens.
(Arch Ophthalmol. 1990;108:842-844)
"D lepharoplasty is
glue is identical to the final normal coagu¬ lation pathway." Platelets and most other
of the most
plastic surgical opera¬ tions. It can be performed either alone common
in combination with other aesthetic and/or reconstructive procedures. The current investigation is concerned with wound closure in blepharoplasty using autologous fibrin glue and a min¬ imal number of sutures. or
Accepted for publication March 22, 1990. Dr Mandel is in private practice in Los Angeles, Calif. Presented at the Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, Calif, January 21, 1990. Reprint requests to Century City Medical Plaza, 2080 Century Park E, Suite 401, Los Angeles, CA 90067-2007 (Dr Mandel).
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/20/2015
RESULTS
complications associated with 16 patients whose eyelid incisions have been closed with only a few sutures and fibrin glue are reviewed in the Table. All of the patients have now been fol¬ The
lowed up for at least 1 year. Milia, su¬ ture cysts, granulomas, and other problems associated with suture clo¬ sure of wounds were not seen. One pa¬ tient developed a wound separation in the immediate postoperative period,
necessitating reclosure. In addition, it was noted that a tincture of benzoin dissolved the autologous glue, preclud¬ ing its use to enhance small tape (Steri-Strip, 3M, St Paul, Minn) adher¬ ence.
All of the patients in this study were in excellent health. Red blood cell re¬ placement was necessary due to losses from other operations performed at the same time. These included reduc¬ tion mammoplasty, abdominoplasty,
Fig 2.—Clotting sequence. The use of fibrinogen and thrombin initiates the final phases of clot¬ ting. Rapid polymerization of the fibrin occurs.
and liposuctioning. None of these pa¬ tients had autologous blood drawn spe¬ cifically for the purpose of having their eyelid incisions closed. There were no complications from the autologous do¬ nation procedure.1 COMMENT
The complication rate from eyelid closure using standard techniques is low.5 Patients may complain about the development of suture cysts, granulo¬ mas, or poor-quality scars. The tech¬ nique utilized prior to availability of fibrin glue included a subcuticular pullout suture for upper eyelid approx¬ imation with the lateral aspect rein¬ forced with a continuous skin suture.6 In the lower eyelid a fine running ny¬ lon suture was used. Other than tech¬ nical errors, many of the known com¬ plications are due to the use of suture material. To avoid such problems, cyanoacrylate glue has been recently recommended as a means to close the incisions.7 Variants of this glue have been available for over 2 decades for of Autologous Fibrin Glue in 16 Patients With
Complications
Blepharoplasty Wound Milia
separation
Suture cysts Granulomas Scar revision
Fig 3.—Top left, Elderly patient undergoing blepharoplasty. The preoperative view shows considerable wrinkling. Top right, The operative view shows the glue being applied. Bottom left, At 4 days, the thin fibrin clot is still seen. Bottom right, The well-healed wound at 1 year is noted.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/20/2015
1
0 0 0 0
wound
closure; however, the cyanoacrylates have not been approved by the Food and Drug Administration (Washington, DC) for human use in
the United States.8 Advocates of the cyanoacrylate eyelid wound closure state that the glue simply peels off and that complications are minimal. The incidence of hypersensitivity and longterm problems for the cyanoacrylate glue products in humans are not known at this time. Autologous fibrin glue is an alterna¬ tive method to close wounds. This ap¬ plication is simple, but care has to be taken since polymerization and devel¬ opment of significant bonding does not occur for several minutes.9 The autol¬ ogous glue, however, goes on to form a firm seal that has sufficient adhesive strength to keep the blepharoplasty incisions closed. The complications noted here were the initial technical ones that occurred from clot dissolu¬ tion by the application of tincture of benzoin. Long-term complications in¬ cluding suture cysts, granulomas, and poor-quality scars were not noted. First described over 70 years ago, tissue glue was rediscovered by Euro¬ pean investigators 20 years ago.1011 A study by Brück12 showed its usefulness in face-lift surgery. Commercially available pooled glue has also been useful in a variety of other surgical procedures, with over 700 reports in the world literature. This product is not available in the United States due to the risk of transfusion-transmitted diseases. A much safer autologous product, however, can be easily pre¬ pared from the individual patient at most hospital blood banks or by com¬ mercial hématologie services. The au¬ tologous preparation eliminates the risk of acquired immunodeficiency syndrome and other transfusiontransmitted infections.
Numerous studies indicate that
au¬
tologous fibrin glue can decrease com¬ plications due to bleeding, shorten the length of operations, and expedite healing.13"" The fibrin glue sets up rap¬ idly, adheres well to wounds, and has strong adhesive properties. Mixing fi¬ brinogen and thrombin initiates the second phase of coagulation with the formation of a fibrin network having considerable bonding power.2 A human dura experimental model was used to compare the strengths of autologous
preparations.9 Al¬ though initially the commercial glue was stronger, by 30 minutes the bond¬ ing power of the autologous glue was much greater. This strength was suf¬ ficient to keep wounds closed even un¬ and commercial
der tension.1819 The current clinical study confirms the adhesive properties of autologous fibrin with only minimal sutures needed to maintain wound co-
aptation.
In select cases, fibrin glue can be used as an alternative technique to close blepharoplasty wounds. The au¬ tologous preparation is superior to the commercial ones since it eliminates the risk of transfusion-transmitted disease. Since fibrin glue is not only adhesive, but also hemostatic, its use is now being extended to other proce¬ dures to determine if problems such as blood loss, hematoma formation, and healing difficulties can be altered in a
positive manner.
References 1. Mandel MA. Autotransfusions in elective
plastic surgical procedures. Plast Reconstr Surg. 1986;77:767-771.
Siedentop KH, Harris DM, Sanchez B. Autologous fibrin tissue adhesive. Laryngoscope. 2.
1985;95:1074-1076. 3. Dresdale A, Rose EA, Jeevanandam V, et al. Preparation of fibrin glue from single donor fresh frozen plasma. Surgery. 1985;97:750-755. 4. Kram HB, Nathan RC, Stafford FJ, Fleming
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/20/2015
AW, Shoemaker WZ. Fibrin glue achieves hemo-
stasis in patients with coagulation disorders. Arch Surg. 1989;124:385-387. 5. Nesi FA, Katzen LB, LiVecchi JT. Complications of blepharoplasty. In: Smith BC, Della Rocca RC, Nesi FA, Lisman R, eds. Ophthalmic Plastic and Reconstructive Surgery. St Louis, Mo: CV Mosby Co; 1987:732. 6. Rees TD. Blepharoplasty: surgical procedures in aesthetic plastic surgery. In: Aesthetic Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1980:470. 7. Kamer FM, Joseph JH. Histoacryl: its use in aesthetic facial plastic surgery. Arch Otolaryngol Head Neck Surg. 1989;115:193-197. 8. Mandel MA. Isolation of mouse lymphocytes for immunologic studies by thoracic duct cannulation. Proc Soc Exp Biol Med. 1967;126:521-524. 9. Siedentop KH, Harris DM, Sanchez B. Autologous fibrin tissue adhesive: factors influenc-
ing bonding
733. 10.
power.
Laryngoscope. 1988;98:731\x=req-\
Grey EG. Fibrin as a hemostatic in cranial Surg Gynecol Obstet. 1915;21:452.
surgery.
11. Matras H. Fibrin sealant in maxillofacial surgery: a review of the past 12 years. Facial Plast
Surg. 1985;2:297-313.
12. Bruck HG. Fibrin tissue adhesion and its in rhytidectomy: a pilot study. Aesthetic Plast
use
Surg. 1982;6:197-202. 13. Dresdale A, Bowman FO Jr, Malm JR, et al. Hemostatic effectiveness of fibrin glue derived from single donor fresh frozen plasma. Ann Thorac Surg. 1985;40:385-387. 14. Spotnitz WD, Dalton MS, Baker JW, Nolan SP. Reduction of perioperative hemorrhage by anterior mediastinal spray application of fibrin glue during cardiac operations. Ann Thorac Surg. 1987;44:529-531. 15. Rousou J, Levitsky S, Gonzalez-Lavin L, et al. Randomized clinical trial of fibrin sealant in
patients undergoing resternotomy or reoperation after cardiac operations: a multicenter study. J Thorac Cardiovasc Surg. 1989;97:194-203. 16. Moretz WH Jr, Shea JJ Jr, Emmett JR, Shea JJ III. A simple autologous fibrinogen glue for otologic surgery. Otolaryngol Head Neck Surg. 1986;95:122-124. 17. Stuart JD, Kenney JG, Lettieri J, Spotnitz W, Baker J. Application of single-donor fibrin glue to burns. J Burn Care Rehabil. 1988;9:619-622.
18. Henrick A, Gaster RN, Silverstone PJ. Or-
ganic tissue glue in closure of cataract incisions. J Cataract Refract Surg. 1987;13:551-553. 19. Steube D, Hamm KD, Pothe H, Schreiber D, Beer R. Fibrin glue on the Cohn I fraction basis in repairing cerebral and dura defects: an experimental study on rats. Folia Haematol (Leipz). 1988;115:213-217.
