A retrospective review of the use of autologous platelet gels for rhytidectomy.

Abstract

Tissue sealants exist in 2 forms: platelet-rich plasma (PRP) and platelet-rich fibrin matrix (PRFM). They both result in activation of fibrinogen to fibrin, but PRFM contains a higher concentration of fibrinogen. PRFM products, otherwise known as fibrin sealants, make use of pooled human donor fibrinogen, factor XIII, and fibronectin. When they are mixed with thrombin, calcium chloride, and aprotinin, a fibrin clot is formed. Fibrin sealants are available as single-use kits. As an example, Evicel (Ethicon 360) comes in a triluminal catheter. One lumen contains the fibrinogen solution; one contains the thrombin solution; and one is filled with air to allow the spray application. On spraying, the fibrinogen and thrombin solutions are mixed, and a fibrin clot is created within seconds. In 2001, our facility compared the severity of edema and ecchymosis with and without the use of autologous PRP in 8 healthy women after standard deep-plane rhytidectomy. Unilateral application of the PRP was performed on closure of the superficial musculoaponeurotic system and skin flaps (Figure). The conclusion from this prospective, randomized, controlled pilot study was that there was a trend toward decreased postoperative ecchymosis and edema on the side of PRP application. The trend was more apparent early in the postoperative period (days 3-12) and more so for ecchymosis than edema. Because of the limited power of the study, however, a statistically significant difference could not be elucidated. In 2009, Lee et al published their results using the fibrin sealant Crosseal (Ethicon Inc) in 9 patients who were undergoing rhytidectomy. The sealant was applied unilaterally at random, and the contralateral side served as the control. The severity of ecchymosis for each side was scored 1 (minimal) to 10 (severe) by 5 blinded observers at postoperative days 3 and 7. The authors found a statistically lower level of ecchymosis for the fibrin sealant side (4.5) as compared with the control (6.2). Zoumalan and Rizk investigated hematoma occurrence with fibrin glue in both deep-plane and lateral superficial musculoaponeurotic system rhytidectomies. In their study, 459 patients underwent skin flap closure with fibrin glue, and 146 patients underwent standard closure. The authors concluded that there was a statistically significant reduction in hematoma rate when fibrin glue was applied to the skin flap. The hematoma rate was 3.4% in the control group and 0.4% in the fibrin sealant group (P=.01). Based on these studies, it seems likely that tissue sealants reduce the severity of ecchymosis in the acute postoperative period and may also minimize hematoma occurrence. It should be noted, however, that many other studies have not been able to corroborate these findings. Perhaps one of the more important and less frequently discussed advantages of fibrin sealants is the reduced operative time to achieve hemostasis and wound closure. Clearly, patients stand to benefit from reduced anesthesia time. However, the reduced facility and anesthesia fees must be weighed against the product expense. The unit cost for 2 mL of fibrin sealant plus the applicator is $200. In our experience, the use of fibrin sealants saves approximately 5 minutes of operative time during rhytidectomy. Because the product costs exceed the reduced facility costs, our facility no longer uses PRP or PRFM. Unfortunately, in our opinion, the potential benefits of these sealants have not been adequately substantiated to justify their costs in rhytidectomy. Figure. Application of platelet-rich plasma to the skin flap during closure of a deep-plane face-lift (reprinted with permission from Powell et al2).