Autologous Fibrin gLue

ORIGINAL ARTICLE AESTHETIC

Use of Autologous Fibrin Glue (Platelet-Poor Plasma)in Abdominal Dermolipectomies

Angelica Maria Schettino • Diogo Franco •

Talita Franco • Joao Medeiros Tavares Filho •

Fabiel Spani Vendramin

Received: 26 January 2012 / Accepted: 17 July 2012

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2012

Abstract

Background Autologous plasma is endowed with prop-

erties that speed up healing, hemostasis, and adhesiveness,

in addition to growth factors. Through an established pro-

tocol, it was possible to isolate thrombin, as well as the

platelet-rich plasma (PRP) and platelet-poor plasma (PPP)

fractions. The purpose of this study was to analyze autol-

ogous use of thrombin and PPP to foster adhesion between

an abdominal dermoadipose flap and the aponeurotic sur-

face in abdominal dermolipectomies.

Methods The data from 40 patients who underwent

abdominal dermolipectomies were analyzed, with 20

patients using thrombin and autologous PPP (Plasma

group) and 20 patients with no intervention (Control

group). An attempt was made to assess adhesive power by

quantifying the serohematic liquid volume gauged during

the postoperative days (POD), and also noting the inci-

dence of seroma. Other variables such as age and body

mass index (BMI) were also analyzed.

Results The reduction in the aspiration drain debit was

statistically relevant only on the first POD in the Plasma

group. There was no reduction in the incidence of seroma

in these patients. Similarly, age and BMI did not influence

these outcomes.

Conclusion The PPP fostered adhesion between the

abdominal dermoadipose flap and the aponeurotic surface

only on the first POD and had no influence whatsoever on

the incidence of seroma. There are few reports on the use

of PPP for plastic surgery, particularly the autologous type,

opening up possibilities for further research projects to

expand its use.

Level of Evidence III This journal requires that authors

assign a level of evidence to each article. For a full

description of these Evidence-Based Medicine ratings,

please refer to the table of contents or the online instruc-

tions to authors www.springer.com/00266

Keywords Platelet-rich plasma � Plasma � Plastic surgery

Introduction

Abdominal dermolipectomy is a surgical procedure that is

undertaken frequently, with seroma a common complica-

tion [1–3], with an incidence of up to 90 % reported for

this type of surgery [4]. In the latest publications, a seroma

incidence of up to 10 % is accepted for dermolipectomies,

although this figure varies depending on the experience of

the surgeon and the body mass index (BMI) of the patient,

in parallel to increasing frequency of seroma in operations

associated with lipoaspiration [4].

Among the latest scientific novelties, fibrin glue is a

promising option for tissue adhesion, with reduced post-

operative edema and the need for drains. It also helps

reduce the occurrence of liquid buildup, seroma, and

hematoma [5]. It is usually produced through plasmaphe-

resis, using a pool of known donors, while thrombin is

animal (bovine) in origin. Inconvenient aspects of fibrin

glue include high cost, the possibility of allergic reaction

A. M. Schettino (&) � D. Franco � T. Franco � J. M. T. Filho

Federal University of Rio de Janeiro, Rua Professor Gabizo,

101 apto. 202-Tijuca, Rio de Janeiro CEP: 20271-063, Brazil

e-mail: [email protected]

A. M. Schettino

Marcilio Dias Navy Hospital, Rio de Janeiro,

Brazil

F. S. Vendramin

Federal University of Para, Belem, Para, Brazil

123

Aesth Plast Surg

DOI 10.1007/s00266-012-9978-y

http://www.springer.com/00266

(as the origin of this substance is bovine), and viral trans-

missions (B19 parvovirus, hepatitis, and HIV), despite

modern viral neutralization techniques [6]. However,

research projects investigating plasma (as well as its

platelet-rich and platelet-poor fractions) offer opportunities

of using an autologous substance with adhesive, healing,

and hemostatic properties at low cost [7–9].

The purpose of this study was to demonstrate the use of

platelet-poor plasma (PPP), also known as fibrin glue, as an

adhesive element in abdominal dermolipectomies and

analyze its action and its effect on the incidence of seroma

among these patients.

Materials and Methods

This study followed 40 patients who underwent abdominal

dermolipectomy (Bozola level V) [10] and collecting data

on daily drainage volumes, length of time the aspiration

drain remained in place, and the incidence of seroma. The

first 20 patients underwent surgery using PPP in the supra-

aponeurotic surface, after resectioning excess skin and

immediately before positioning the dermoadipose flap

(Plasma group). The other 20 patients underwent abdomi-

nal dermolipectomy with no products applied (Control

group). A continuous aspiration drain was used for all

patients using the same surgical technique.

The PPP was isolated in an autologous manner through

successive centrifugation steps, following the protocol

developed by Vendramin et al. [11]. The thrombin used to

activate the plasma was also isolated through the same

protocol, also in an autologous manner (Fig. 1). The drains

were kept in place until the daily volume reached a max-

imum value of 50 ml/24 h.

The patients were between 20- and 60-year-old, with a

minimum hematocrit index of 37 %, normal laboratory

tests, a surgical risk rated at American Society of

Anesthesiologists (ASA) I or II according to the ASA , and

a BMI of no more than 27 kg/m2. All were women who

gave written informed consent. There was no association of

surgical procedures, and all patients wore surgical support

belts for at least three months after the operation (Fig. 2).

Results

Both groups were similar in terms of age, BMI, and labo-

ratory test results. The average volume on the first postop-

erative day (POD1) in the Plasma group (P group) was 53.2

and 105.1 ml on the POD2, with this difference being sig-

nificant (p = 0.006). There were no statistical differences

for the other POD in the P group. For the Control group (C

group), the mean aspiration drain volume for POD1 was

103.7 ml and for POD2 it was 105.2 ml. There was no

difference in volume on any other POD (Table 1). When

comparing the two groups, a statistically significant reduc-

tion in the aspiration drain debit was noted (p = 0.004) only

on the POD1 and was not repeated on the other POD

(Table 2). A curve of the mean daily volumes of both groups

versus POD (Fig. 3) was constructed, demonstrating a

reduction in the aspiration drain debit for patients in the P

group. Although it was statistically relevant only on the

POD1, it may be said that the plasma generally reduced the

volume from drains used in the operations.

Another evaluation measured the incidence of seroma,

noted at 20 % in the C group and reaching 35 % in the P

group. For all the patients who underwent surgery, the

incidence of seroma reached 27.5 %, mainly in the P group

(Table 3). Thus, comparing the two groups, there was no

statistical relevance in the incidence of seroma, with

p = 0.288, according to the v2 test analysis.

Finally, the BMI and seroma were analyzed for any

correlation between these variables. There were no statis-

tically significant findings between these data for either of

the two groups (Tables 4, 5).Fig. 1 Activation of plasma by thrombin

Fig. 2 Application of activated plasma to the aponeurotic surface

Aesth Plast Surg

123

Discussion

Platelets play an important role in coagulation and tissue

healing. Once platelets are activated, a lot of cytokines and

growth factors are released, which trigger important actions

such as hemostasis, coagulation, and healing. Their roles

are well known in healing chronic wounds and in knitting

partial skin grafts together [7–9, 11–14].

Two plasma fractions may be isolated from full blood,

thus constituting a concentrate with a higher or lower level

of platelets: platelet-rich plasma (PRP) and PPP. There are

various types of protocols available in the literature [11,

14–18]. The protocol used in this study produces outcomes

similar to those found by the main authors in this field and

can isolate both plasma fractions at the same time. Fur-

thermore, it is also possible to isolate and produce the

thrombin that is used to activate the plasma. This produc-

tion method makes the use of activated plasma safer

because it works with autologous rather than bovine

thrombin. Thus, platelet-rich and platelet-poor autologous

plasma are endowed with properties that are important for

healing, adhesion, and hemostasis. The PPP is compared to

fibrin glue and is, in fact, known by this name by several

authors [9, 19–22] as it is endowed with a sealing action

similar to industrially produced glue. The use of autologous

Table 1 Descriptive statistics of serohematic liquid volumes (ml) by

POD

Descriptive statistics 1

POD

2

POD

3

POD

4

POD

5

POD

6

POD

Plasma group

N 20 20 17 11 5 2

Mean 53.2 105.1 70.5 50.5 36.0 60.5

Standard deviation 26.7 101.8 38.1 23.8 24.1 29.0

Minimum 10.0 20.0 14.0 20.0 0.0 40.0

Median 62.0 75.0 67.0 50.0 45.0 60.5

Maximum 102.0 450.0 185.0 107.0 62.0 81.0

Control group

N 20 20 19 13 9 4

Mean 103.7 105.2 78.4 68.2 57.0 52.3

Standard deviation 65.8 63.9 42.9 39.5 17.8 9.9

Minimum 13.0 35.0 30.0 18.0 35.0 45.0

Median 91.5 85.0 64.0 64.0 55.0 49.0

Maximum 248.0 273.0 178.0 150.0 90.0 66.0

p-value by the

Mann-Whitney test

(comparison

between the

groups)

0.004 0.441 0.763 0.339 0.159 1.000

Table 2 Comparison between the POD1 and other days, among days and between groups

Descriptive statistics 2 POD 3 POD 4 POD 5 POD 6 POD

Plasma group

N 20 17 11 5 2

Mean 51.9 17.7 -9.2 -30.6 -23.0

Standard deviation 94.4 37.9 25.4 52.4 2.8

Minimum -45.0 -51.0 -50.0 -102.0 -25.0

Median 29.5 14.0 -10.0 -35.0 -23.0

Maximum 348.0 96.0 40.0 38.0 -21.0

p-value (Wilcoxon test) 0.006 0.072 0.182 0.225 0.180

Control group

N 20 19 13 9 4

Mean 1.5 -26.8 -29.0 -42.0 -33.5

Standard deviation 80.2 91.7 84.7 75.5 61.8

Minimum -155.0 -218.0 -156.0 -175.0 -97.0

Median 1.5 -15.0 -25.0 -32.0 -44.0

Maximum 190.0 165.0 135.0 55.0 51.0

p-value by the Wilcoxon test (comparison of days with a POD1) 0.955 0.191 0.249 0.161 0.465

p-value by the Mann-Whitney test (comparison between the groups) 0.064 0.035 0.325 0.947 0.355

Table 3 Incidence of seroma in the Plasma and Control groups

Group Total Without

seroma

Seroma p-value

by the test

n % n % n % v2

Plasma 20 100.0 13 65.0 7 35.0 0.288

Control 20 100.0 16 80.0 4 20.0

Total 40 100.0 29 72.5 11 27.5

Bold values indicate the percentual of patients that did not have

seroma

Aesth Plast Surg

123

thrombin and PPP eliminates the possibility of viral

transmission and allergic reactions.

With the use of PPP in abdominal dermolipectomy, we

analyzed its sealing and hemostatic powers, noting that its

behavior is similar to that of industrial glue. There are few

reports on the use of PPP in surgery, particularly the

autologous type. This plasma fraction was selected because

it has been compared to biologic glues and because of its

adhesive action. We chose to use it for abdominal

dermolipectomy because this operation involves ample

tissue separation and there was the possibility of monitor-

ing the daily aspiration drain debit. The incidence of ser-

oma also prompted this survey.

Satisfactory results on only the POD1 in the P group

shows that the PPP was effective in reducing liquid buildup

and exudation during the postoperative period, and when

comparing the outcomes for the two groups, there was a

significant reduction in the debit in the P group. The high

drain volumes on the subsequent POD, reaching levels

equivalent to those of the C group, may be explained by the

useful life span of the plasma and the conditions under

which the PPP was used. The application of PPP took place

at room temperature, and the plasma was activated and

Fig. 3 Postoperative volumes by group

Table 4 Descriptive statistics on age and BMI by seroma incidence in the Control group

Statistics Seroma p-value*

No (n = 16) Yes (n = 4)

Age (years) Mean 41.9 41.8 0.750

Standard deviation 8.9 15.4

Minimum 33.0 28.0

Median 38.0 39.5

Maximum 59.0 60.0

BMI (kg/m2) Mean 23.4 23.4 0.963


Minimum 19.5 21.6

Median 23.9 23.3

Maximum 26.1 25.6

*Mann-Whitney test

Table 5 Descriptive statistics on age and BMI by seroma incidence in the Plasma group

Statistics Seroma p-value*

No (n = 13) Yes (n = 7)

Age (years) Mean 39.4 45.4 0.211


Minimum 23.0 31.0

Median 35.0 47.0

Maximum 60.0 60.0

BMI (kg/m2) Mean 23.2 23.4 0.877


Minimum 18.1 20.7

Median 23.9 23.6

Maximum 26.4 25.5

*Mann-Whitney test

Aesth Plast Surg

123

applied with thrombin up to 4 h after it was made. The

importance of the plasma temperature is related to its sta-

bility and viability; at temperatures between 22 �C and

24 �C, plasma must be used within 5 h [23].

Several attempts have been made in plastic surgery to

develop techniques and tactics for reducing the volume and

incidence of seroma. A seroma rate of up to 10 % is

acceptable, but in the literature it ranges from 0.3 to 90 %

[6]. There have also been discussions on what might

influence the incidence of seroma. There are some firmly

established techniques for reducing seroma in abdomino-

plasty, such as the Saldanha [24] technique and Baroudi

[25] stitches. However, although the Saldanha surgical

technique has had good outcomes in terms of reducing the

incidence of seroma, its use is limited, particularly for

operations in which large abdominal volumes are resec-

tioned. In addition, the association of lipoaspiration with

surgery was excluded here.

Thus, the incidence of seroma in this study, 35 % in the

P group and 20 % in the C group, was higher than the mean

rate accepted in some studies, with no statistical relevance

when the groups are compared (p = 0.288). The P group

had more seroma but it can not be said that this (the use of

PPP) was the determining factor in this occurrence.

The absence of correlation between seroma and BMI

was also noted in both groups, contradicting the daily

practice of all plastic surgeons, particularly because a

higher seroma index is noted in overweight patients. The

absence of correlation may be related to the inclusion

factors for this study, which limited patient BMI to 27 kg/

m2, thus excluding overweight or obese patients. Thus,

sufficient data were not available to analyze whether this

variable might be effective. In future studies, the BMI

should not be limited, obviously provided that this is not a

clear counterindication for the operation.

The cost of obtaining autologous plasma, considering

both plasma fractions, was lower than that of industrial

glue. The average amount spent on this autologous pro-

duction varied between US$12.00 and US$30.00, which is

very different from the cost of industrial glues or machines

that produce PRP with kits, which are around US$175.00/

ml. In fact, the need for PRP production kits, whether

autologous or not, also hampers its use. All this merely

underscores the need to extend research in this field of

medicine, making better use of substances that speed up

healing and make flap adhesiveness a reality.

Conclusion

Platelet-poor plasma reduced the continuous aspiration drain

debit in the patients studied only during the POD1. There was

no link between the incidence of seroma and PPP. In the P

group, the BMI did not influence the incidence of seroma.

This consequently indicates the need for additional studies to

examine the properties and possibilities of plasma use, for

both fractions, including comparative studies on the out-

comes of autologous and industrial production. Furthermore,

the use of autologous plasma must be extended in operations

in various specialties to open up greater possibilities and

achieve more discoveries with this substance.

Conflict of interest The authors have no conflict of interest to

disclose

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