Fibrin Glue in Face Lifts Since 1978 we have used fibrin glue in face lifts routinely and will continue to use it because it has the following advantages: Prevention of hematoma Reduction of operating time Reduces the need for drains Reduction of tension on the flap Reduction of sutures (wound closure in eyelid surgery) 6. Minimizes swelling 7. Shortens recovery time 1. 2. 3. 4. 5.
patient as well as an additional risk for infection. So the best course would be no postoperative bleeding and no drainage. To reach this goal, it is necessary after very careful hemostasis to close also the small vessels that do not bleed during the operation because of the vasoconstrictive effect of the local anesthetics. Fixing the skin flap with a resorbable sealant at the end of the face lift could manage this problem. The difference between this indication in cosmetic surgery and the one reported until 1977 was the larger space that is necessary to be treated in an almost visible area. Therefore we tested the fibrin glue on experimental animals9 before we used it in humans. Our investigation showed the following results:
Fibrin was already being used during the first World War I by Grey' for topical hemostasis. In 1944 Cronkite et a12 were the first to fix skin grafts with 1. No fundamental difference in wound healplasma and thrombin. However, the strength and stability of the fibrin film was insufficient, since the ing between fibrinogen and suture-fixed source of fibrinogen was plasma, which has low flaps. concentration of fibrinogen. In the early 1970s at2. Quick resorption. (After 5 days the 1251 tagged fibrinogen has disappeared.) tempts were successful in increasing fibrinogen con3. Good tissue compatibility. centration and Matras et als5 used this more effective fibrin clot sealant to reunite peripheral nerves Now, the application of fibrin glue is very popular in and for microanastomoses in vessels.6 When we heard about their successful nerve anas- all kinds of surgery. The preparation of the sealant tomoses with a biologic sealant and about the essen- can be modified as needed with a quick or slower tial work of Spengler7 about this glue we thought clotting time.loJ1 Deep frozen, or lyophilized, fithat such a resorbable biologic system, which imi- brinogen may be used. tates a physiologic process, may be useful in plastic For face lift we use the following solutions: surgery of the face to reduce the postoperative discomfort.8 1. Haemocomplettan HS, a dry substance One of the problems of the face lift is the avoidance (Trockensubstanz) containing 2 gm human fibrinogen that has been kept by the pharof postoperative bleeding. Hematoma is a complication with which even the best surgeon has somemaceutical company for 20 hours in a water times to cope, especially when wide undermining is solution at a temperature of 60°C in order to inactivate possibly DNS and RNS viruses, necessary. In order to prevent this normally, drainsuch as human immunodeficiency virus I age was used. But a drain is a discomfort for the
Clinical Professor, Berlin, Germany Reprint requests: Dr. Flemming, Burgunder Strasse 9, D-1000 Berlin 38, Germany Copyright 01992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved
Downloaded by: National University of Singapore. Copyrighted material.
Irene Flernrning, M . D.
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
FACE LIFT Aim and Indication
For an ambitious surgeon, it is seducing to make the very best out of a face using all operative possibilities available, modeling skin, muscle, fat, and bone, putting, when needed, malar, chin, or frontal implants, and so on, until the face comes nearest to perfection as possible. However, our aim for a face lift is another, a more reconstructive, one. We do not dare to alter the personality of a person, but we try to help patients with visible stigmata of illness, misfortune, or personal poor behavior (for example, obesity, inadequate sun exposure) to a normal condition. In such cases the external appearance of the patient gives a false picture of the true personality. They are healthy, full of activity, and have positive feelings, but their faces looks ill, tired, angry, or
neglected. Good makeup is not sufficient because of the laxity of the skin. After surgery, the patient should not have an "operated on" look, but should look healthy and well-recreated. The flaccidity of the skin leads to the following deformities (Fig. 1): 1. Jowl formation 2. Deep overlapping nasolabial folds 3. Vertical folds on the comer of the mouth 4. Vertical flabby folds on the neck (turkey neck) 5. Preauricular folds 6. Sagging of the eyebrows.
When one or more of these signs are present, there is an indication for rhytidectomy regarded from a technical view. In regard to the skin, the ideal candidate for rhytidectomy has a well-attended healthy soft skin with sufficient elasticity left, and not a sunbaked leathery inelastic, wrinkled, or acne-scared skin texture. Selection of Patients
We perform face lifts as an outpatient procedure using local anesthesia. Therefore the selection of
-
..
Figure 1. A: A 55-year-old patient showing all kinds of deformities due to skin flaccidity; B: 14 days after normalization of skin tension without any adjunctive procedures (note the reposition of the left eyebrow).
80
Downloaded by: National University of Singapore. Copyrighted material.
and I1 or hepatitis virus. The fibrinogen is dissolved in 100 ml aqua destillata. 2. One bottle of Topostasin sterile dry substance (Trockensubstanz) containing 3000 NIH U of thrombin is dissolved in 2 ml aprotinin (Trasylol) and 3 ml calcium chloride (0.025 mmol~liter).
Figure 2. A: A 43-year-old woman before surgery; B: 1 days after face lift, with no liposuction or superior musculoaponeurosis system procedure.
the patients has to take into consideration this fact. These are the conditions for the patient: 1. Mentally and physiologically healthy 2. Disciplined 3. Acceptance of the discussed result, type, extent, and possible complications of the operation 4. A nice, well-maintained home 5. A relative or friend who cares for the patient
bercle. The amount of skin that has to be removed to obtain a new normal skin tension in the remaining skin flap is marked, the excess skin is excised. The flap is reattached to the temple, jaw, and neck with fibrin glue, and the wounds are closed. Fibrin sealant does not only assicurate hemostasis but ensures the normal tension on the flap. The glue will not fix if there is any tension on the flap. This is a simple operation when every step is carefully done and can be repeated several times. A secondary lift in our patients is generally done after 8 to 10 years (Fig. 3).
Principles of the Operation Preoperative Procedures and Planning
The classic rhytidectomy is an operation of the skin. Our aim in face lifts is to normalize skin tension of the face and neck.lzThus, the skin and subcutaneous tissue of the temple, the jaw, and the neck must be undermined until the last fold to be corrected is reached. Sometimes it is necessary to undermine the whole neck in order to pass from one side to the other. When the elevation of the skin flap is done, additional surgery, such as liposuction or elevation of the superior musculoaponeurotic system (SMAS) may be necessary (Fig. 2). The skin flap is then elevated in an opposite direction to which it has sagged, that is, the flap is elevated in all parts and pulled gently over the ear toward Darwin's tu-
Photographs are taken of the front and both sides of the face, while laughing and relaxed. The photographs of movement of the face are of great importance to detect possible weakness of the facial nerve and to have a picture of muscle function. Together with the patient these photographs are carefully analyzed and any asymmetries, such as a difference of the eyebrow heights or a deeper nasolabial fold on one side, are discussed. The features of the skin and the visible signs of aging due to diminished skin elasticity are shown; but also crows feet, frown lines, and vertical lines on the lips or deformities of the eyelids, such as fat bags, are pointed
Downloaded by: National University of Singapore. Copyrighted material.
FIBRIN GLUE IN FACE LIFTS-Flemming
Downloaded by: National University of Singapore. Copyrighted material.
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Figure 3. A: A 70-year-old woman before; after a face lift; C: 11 years postoperatively.
3 weeks
FIBRIN GLUE IN FACE LIFTS-Flemming
Prernedication and Preparation
When the patient arrives for surgery, the hair is saturated with an alcoholic solution, an area of approximately 3 cm is shaved over and behind the ear, and the rest of the hair is tied in tufts (Fig. 4). Once blood pressure is taken, a premedication of
Figure 4.
Preparation of the hair before surgery.
50 mg promethazine hydrochloride (Atosil),0.5 mg atropine, and 15 mg pentazocine (Fortral) is given. Intravenous infusion of physiologic saline solution is given. Blood pressure and heart rate are monitored continuously. Local Anesthesia
For local anesthesia we use a solution of 0.5% lidocaine (5 mg) with epinephrine (0.01 mg) for 30 or 40 cm3 on each side. This solution is given as an intracutaneous injection along the incision lines and subcutaneously in the area to be undermined. Disinfection is done using a povidone-iodine alcohol solution. A sterile towel is fixed with sutures on the posterior side of the shaved area. Operative Technique
We prefer the double S incision described by Pitanguy.13It starts in the temple within the hairline, curves downward crossing the rim of the tragus, passes around the earlobe to the posterior concha1 surface, and ends in the postauricular area of the scalp. The marking of the double S incision is done with brilliant green (Fig. 5). The skin is incised along the marked line. The
Figure 5. Marking of double S incision and direction of skin reposition.
Downloaded by: National University of Singapore. Copyrighted material.
out. The importance that the patient attaches to each of them is noted and explanations are given concerning what can and cannot be corrected by face lift. The patient must understand that rhytidectomy corrects basically the skin tension and that only the folds caused by laxity of the skin will be gone after surgery but the fine, deep wrinkles often due to sun exposure will not be removed, only ameliorated. Such wrinkles require dermabrasion or chemical peel. Likewise, the deep nasolabial fold must be corrected by additional injections of collagen. The incisions are marked on the photographs, even the necessary undermining of the skin flap. The expected surgical result is once more discussed with the patient. The patient's health must be good and under the supervision of an internist. Women should not be menstruating or within 10 days of menstruation. The patient should avoid stress and relax the week before surgery. The hair should not be cut short and must be washed the day prior to surgery.
temporal and retroauricular part of the incision is made with the scalpel blade directed forward to preserve the hair follicles in the posterior wound margin. Undermining is done subcutaneously using first the scalpel and proceeding with scissors. In the area above the zygomatic arch, the level of undermining is beneath the temporal fascia. Care must be taken in the area beneath the nonhair-bearing skin over the temple to avoid damage to the temperofrontal branch of the facial nerve. Dissection should therefore be continued superficially in this region. Undermining in the face and neck are then completed. When necessary the whole neck is undermined to make it possible to pass from one side of the face to the other. The next step is to determine whether further procedures (elevation of the SMAS or fat removal) are necessary. We perform these after the skin is completely undermined, fixing the SMAS with one key suture and fibrin glue. If fat removal is necessary, liposuction is used. An accurate hemostasis is very important, even when the fibrin glue is used to avoid postoperative hematoma. The new skin tension is marked first in the facial region by pulling the undermined skin Figure 7. Key suture in the temple area. gently in the direction of the Darwin process (Fig. 6). The skin is incised until the marked point and a key suture is taken in the region above the ear (Fig. 7). The overlapping skin in the temporal region is then marked with brilliant green and excised. The same procedure is followed in the netck where the skin is gently pulled in the direction of the Darwin process (Fig. 8). Once the skin to be removed has been marked, it is then incised and a key suture is taken in the mastoid region. The overlapping skin is excised after the amount to be removed has been marked. The remaining skin is then pulled over the ear without tension and the excessive skin is marked and then excised (Fig. 9). The fibrin glue is applied after hemostatic stability has been ascertained. We use a long-button cannula to reach the whole undermined area without damaging the tissue. We start from the temporal region and move toward the face and neck applying first the thrombin and then the fibrinogen (Fig. 10). Using gentle pressure on the face and neck the surplus of fibrin glue is pressed out (Fig. 11). It is important to use only a thin layer of fibrin. Care must be taken not to press too hard on the skin to avoid necrosis. Suturing of the skin completes the intervention. Dressing and Postoperative Care
1
Figure 6. Mark~ngof the amount of sk~nthat needs to be resected In the temple region.
Povidone-iodine ointment is put on gauze and placed over the sutures and a circular head dressing is with a very light pressure. After surgery, the patient relaxes in bed in an
Downloaded by: National University of Singapore. Copyrighted material.
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Figure 8. Marking of the amount of skin that needs to be resected in the mastoid region.
Figure 9. the ear.
Figure 10. Application of fibrin glue with a long button cannula.
Marking of excessive skin before and behind Figure 11. The surplus of fibrin glue is pressed out.
Downloaded by: National University of Singapore. Copyrighted material.
FIBRIN GLUE IN FACE LIFTS-Flemming
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Complications
Hematoma The most common complication of rhytidectomy is a postoperative hematoma. Large hematomas must be pressed out to avoid infections or necrosis of the skin that cannot be nourished from the underlying tissue. Small hematomas become organized, leaving hard regions that disappear after 6 months or so. Prevention requires meticulous hemostasis. The application of fibrin glue helps a good deal. In fact, since 1976 when we first used the fibrin glue in face lifts, we have seen only one really large hematoma, 36 hours after surgery that required a return to the operating theatre to close the bleeding vessel (Fig. 13). Infections Infections occur very seldom in the face, especially as a result of cosmetic surgery in healthy patients. Necrosis of the Skin Irritation of the skin is always a symptom of bad nutrition of the skin flap and is fortunately very rare. It may occur: 1. by putting too much tension on the flap 2. by dissecting the flap in a plane that is too thin 3. by leaving a too thick layer of fibrin glue 4. by putting too much pressure on the skin flap when extra fibrin glue is pressed out (Fig. 14) 5. by leaving a large hematoma untreated 6. following infections.
Figure 12. A 40-year-old patient 1 day after face lift.
Nerve Injury Facial Nerve. A lesion of the facial nerve is most irregular because of its anatomic position in the parotid gland. The dissection of the skin flap is made above the parotid capsule, threatening only the frontal branch of the facial nerve during dissection of the temple region and the marginal mandibular branch undermining the skin in the mandibular region. Although it is a very rare complication, if the nerve is cut there will be no spontaneous regeneration and it will be impossible for the patient to move the damaged part of her face. Injury to the nerve is avoidable if the flap is undermined in the correct plane. Auricular Nerve. Damage to the auricular nerve will lead to a persistent insensibility of the auricle. This complication also occurs very rarely but is more common than lesions of the facial nerve. The risk occurs when the posterior border of the sternocleidomastoid muscle is dissected too deeply.
Downloaded by: National University of Singapore. Copyrighted material.
upright position cooling the face with ice packs for 1 to 2 hours until the blood pressure has stabilized and a normal condition of the patient is assured. Then the patient may return home. The patient should not stay in bed but behave as usual, of course, without moving the operated area. Walks of 95 to 1 hour twice a day are recommended. Gymnastic or other sports will be followed by an increase in the blood pressure and must be avoided, as well as moving the face and neck, in order to prevent hematoma (no laughing, speaking, eating hard food for 5 days). The first day analgesics may be given if required. There is no other medication, especially no antibiotics. By the first operative day the patient should be pain free. The dressing is changed at this time (Fig. 12) and removed on the fourth day. Only a spray dressing is used to protect the sutures. On the fifth day the hair can be washed. The stitches are removed between the sixth (preauricular)and 12thday. Postoperative photographs are taken at 2 weeks. We advise the patient to massage the scars around the ear lobe and the retroauricular region with Contractubex and to see his or her doctor the moment the scars seem to become harder. Generally we see the patient 6 months to a year after surgery for a last check-up and to take photographs.
Figure 13. A: A 63-year-old patient before face lift; B: 11 months after surgery followed by complication of a large hematoma.
-
-
Damage to the Parotid Gland
Injury to the glandular lobules is a rare complication that is followed by a parotid fistula. X-ray treatment is necessary to close the fistula.
i
Deformity of the Ear Lobe Giving too much tension on the skin flap in the auricular region will result in an ear lobe that is too long. Using fibrin glue will provide this deformity. Bad Scarring The causes of unpleasant scars are: 1. too much tension 2. healing by secondary intention (after press-
3. a disposition for hypertrophic scars. Bad scarring is the most common complication and occurs mostly in the region of the mastoid and the ear lobe. It very seldom occurs before the ear or in the hair. Figure 14. Skin necroses behind the ear due to too much pressure on the skin flap pressing out the surplus of fibrin glue.
Hair Loss Hair loss may occur for following reasons:
Downloaded by: National University of Singapore. Copyrighted material.
FIBRIN GLUE IN FACE LIFTS-Flemming
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Haemocomplettan HS and Topostasin. However, there are sets of fibrin glue available ready for application with double canula or as a spray set. The sets are very helpful in sealing small areas or skin flaps. However, the sets are not adequate for sealing the already fixed skin flap in face lifts; the double canula produces an immediate clotting of the glue and so it Allergic Reaction is not sure that every angle of the wound can be By using the fibrin glue there is a possibility of reached with a thin fibrin film. For this purpose the immediate allergic reactions type I or late allergic spray seems to be better. The disadvantage of the reactions type 11. This complication is very rare and spray is that it has to be applied from a distance of 10 can be treated successfully with immediate cortico- to 20 cm from the area to be sealed. This is impossteroid (250 mg prednisolone) on the first and sec- sible after an extensive undermining passing from ond days and additional application of antihista- one side to the other. In less extensive undermined regions, fibrin spray may be used before key sutures mines for 1 week. above the ear and in the mastoid region are placed. We think there is more disadvantage than advantage proceeding this way. DISCUSSION In our hands the use of fibrin glue in face lifts gives not only the advantage of a shorter operating time or a reduction in drains, but also minimal postoperative swelling, a quicker recovery time, and a recovery that is, in general, free of complications. Because we are performing the face lift using local anesthesia and as an outpatient procedure, it is extremely important not to have postoperative complications, especially no hematoma. To achieve this effect, all small vessels and capillaries must be closed with the seal, mainly those that are not bleeding during the operation due to the vasoconstrictive effect of epinephrine added to the local anesthesia; if only a small area is not reached by the glue, bleeding may occur in this region, when the vasoconstrictive effect is over. A hematoma will be the result; therefore we prefer to apply the fibrin glue with a long button canula. This is logically preceded by undermining of the skin, meticulous hemostasis, and fixing of the flap in normal skin tension with two key sutures. With the long button canula, we are sure to reach the whole undermined area without damaging the tissue. We start from the temporal region and move toward the face and neck, applying first thrombin and than the fibrin glue. Using gentle pressure on the face and neck, the surplus of the fibrin glue is pressed out. It is important to use only a thin layer of fibrin glue. Care must be taken not to press too hard to avoid skin necrosis. As already discussed we use
REFERENCES 1. Grey EG: Fibrin has a hemostatic in cerebral surgery Surg Gynecol Obstet 21:452-454, 1915 2. Cronkite PE, Lozner EL, Deaver JM: Use of thrombin in skin grafting. JAMA 124:976-978, 1944 3. Matras H: Die Wirkungen verschiedener Fibrinpraparate auf Kontinuitatstrennungen der Rattenhaut. Osteer Z Stomat 67:338, 1970 4. Matris H, Dinges HE Lassmann H, Mamoli B: Zur nahtlosen interfaszikularen Nerventransplantation im Tierexperiment. Wien Med Wochenschr 122:517, 1972 5. Matras H, Braun E Lassmann H, et al: Plasma clot welding of nerves (experimental report) J Maxillofac Surg 1:236, 1973 6 . Matras H, Chiari FM, Kletter G, Dinges HP: Zur Klebung von MikrogefiiPanastomosen. Bericht der 13. Jahrestagung der Deutschen Gesellschaft fiir plastische und Wiederherstellungschirurgie. Sept. 1975. ~ i u t t ~ a rGeorg t: Thieme Verlag, 1977, v 57 7. spangier HP: Gewebeklebung und lokale Blutstillung mit Fibrinogen, Thrombin und Blutgerinnungsfaktor XIII. Wien Klin Wochenschr 88 (Suppl 49):l-18, 1976 8. Piechotta FU, Flemming I: Fibrinogen adhesive in plastic surgery In: Plastic and Reconstructive Surgery of the Head and Neck. The Third International Symposium, Vol 1: Aesthetic Surgery. New York: Grune & Stratton, 1981, pp 195-198 9. Piechotta FU, Flemming I: The maximization of wound healing with fibrin glue. Aesthetic Plast Surg 7%-82, 1983 10. Minazzer H: Fibrin sealing: Physiology and Biochemical Background. Facial Plast Surg 2:291-295, 1985 11. Red1 H, Schlag G: Principles of fibrin sealant and its mode of application. Facial Plast Surg 2:315-326, 1985 12. Flemming I: Surgery of the aging face, the face lift. Facial Plast Surg 2:363-370, 1985 13. Pitanguy I: Aesthetic Plastic Surgery of Head and Body. Berlin: Springer-Verlag, 1981
Downloaded by: National University of Singapore. Copyrighted material.
1. Damage done to the hair roots during dissection of the skin flap. 2. Too much tension on the hair-bearing skin flap 3. Tying the sutures too tightly. 4. As a result of skin necrosis.
patient as well as an additional risk for infection. So the best course would be no postoperative bleeding and no drainage. To reach this goal, it is necessary after very careful hemostasis to close also the small vessels that do not bleed during the operation because of the vasoconstrictive effect of the local anesthetics. Fixing the skin flap with a resorbable sealant at the end of the face lift could manage this problem. The difference between this indication in cosmetic surgery and the one reported until 1977 was the larger space that is necessary to be treated in an almost visible area. Therefore we tested the fibrin glue on experimental animals9 before we used it in humans. Our investigation showed the following results:
Fibrin was already being used during the first World War I by Grey' for topical hemostasis. In 1944 Cronkite et a12 were the first to fix skin grafts with 1. No fundamental difference in wound healplasma and thrombin. However, the strength and stability of the fibrin film was insufficient, since the ing between fibrinogen and suture-fixed source of fibrinogen was plasma, which has low flaps. concentration of fibrinogen. In the early 1970s at2. Quick resorption. (After 5 days the 1251 tagged fibrinogen has disappeared.) tempts were successful in increasing fibrinogen con3. Good tissue compatibility. centration and Matras et als5 used this more effective fibrin clot sealant to reunite peripheral nerves Now, the application of fibrin glue is very popular in and for microanastomoses in vessels.6 When we heard about their successful nerve anas- all kinds of surgery. The preparation of the sealant tomoses with a biologic sealant and about the essen- can be modified as needed with a quick or slower tial work of Spengler7 about this glue we thought clotting time.loJ1 Deep frozen, or lyophilized, fithat such a resorbable biologic system, which imi- brinogen may be used. tates a physiologic process, may be useful in plastic For face lift we use the following solutions: surgery of the face to reduce the postoperative discomfort.8 1. Haemocomplettan HS, a dry substance One of the problems of the face lift is the avoidance (Trockensubstanz) containing 2 gm human fibrinogen that has been kept by the pharof postoperative bleeding. Hematoma is a complication with which even the best surgeon has somemaceutical company for 20 hours in a water times to cope, especially when wide undermining is solution at a temperature of 60°C in order to inactivate possibly DNS and RNS viruses, necessary. In order to prevent this normally, drainsuch as human immunodeficiency virus I age was used. But a drain is a discomfort for the
Clinical Professor, Berlin, Germany Reprint requests: Dr. Flemming, Burgunder Strasse 9, D-1000 Berlin 38, Germany Copyright 01992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved
Downloaded by: National University of Singapore. Copyrighted material.
Irene Flernrning, M . D.
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
FACE LIFT Aim and Indication
For an ambitious surgeon, it is seducing to make the very best out of a face using all operative possibilities available, modeling skin, muscle, fat, and bone, putting, when needed, malar, chin, or frontal implants, and so on, until the face comes nearest to perfection as possible. However, our aim for a face lift is another, a more reconstructive, one. We do not dare to alter the personality of a person, but we try to help patients with visible stigmata of illness, misfortune, or personal poor behavior (for example, obesity, inadequate sun exposure) to a normal condition. In such cases the external appearance of the patient gives a false picture of the true personality. They are healthy, full of activity, and have positive feelings, but their faces looks ill, tired, angry, or
neglected. Good makeup is not sufficient because of the laxity of the skin. After surgery, the patient should not have an "operated on" look, but should look healthy and well-recreated. The flaccidity of the skin leads to the following deformities (Fig. 1): 1. Jowl formation 2. Deep overlapping nasolabial folds 3. Vertical folds on the comer of the mouth 4. Vertical flabby folds on the neck (turkey neck) 5. Preauricular folds 6. Sagging of the eyebrows.
When one or more of these signs are present, there is an indication for rhytidectomy regarded from a technical view. In regard to the skin, the ideal candidate for rhytidectomy has a well-attended healthy soft skin with sufficient elasticity left, and not a sunbaked leathery inelastic, wrinkled, or acne-scared skin texture. Selection of Patients
We perform face lifts as an outpatient procedure using local anesthesia. Therefore the selection of
-
..
Figure 1. A: A 55-year-old patient showing all kinds of deformities due to skin flaccidity; B: 14 days after normalization of skin tension without any adjunctive procedures (note the reposition of the left eyebrow).
80
Downloaded by: National University of Singapore. Copyrighted material.
and I1 or hepatitis virus. The fibrinogen is dissolved in 100 ml aqua destillata. 2. One bottle of Topostasin sterile dry substance (Trockensubstanz) containing 3000 NIH U of thrombin is dissolved in 2 ml aprotinin (Trasylol) and 3 ml calcium chloride (0.025 mmol~liter).
Figure 2. A: A 43-year-old woman before surgery; B: 1 days after face lift, with no liposuction or superior musculoaponeurosis system procedure.
the patients has to take into consideration this fact. These are the conditions for the patient: 1. Mentally and physiologically healthy 2. Disciplined 3. Acceptance of the discussed result, type, extent, and possible complications of the operation 4. A nice, well-maintained home 5. A relative or friend who cares for the patient
bercle. The amount of skin that has to be removed to obtain a new normal skin tension in the remaining skin flap is marked, the excess skin is excised. The flap is reattached to the temple, jaw, and neck with fibrin glue, and the wounds are closed. Fibrin sealant does not only assicurate hemostasis but ensures the normal tension on the flap. The glue will not fix if there is any tension on the flap. This is a simple operation when every step is carefully done and can be repeated several times. A secondary lift in our patients is generally done after 8 to 10 years (Fig. 3).
Principles of the Operation Preoperative Procedures and Planning
The classic rhytidectomy is an operation of the skin. Our aim in face lifts is to normalize skin tension of the face and neck.lzThus, the skin and subcutaneous tissue of the temple, the jaw, and the neck must be undermined until the last fold to be corrected is reached. Sometimes it is necessary to undermine the whole neck in order to pass from one side to the other. When the elevation of the skin flap is done, additional surgery, such as liposuction or elevation of the superior musculoaponeurotic system (SMAS) may be necessary (Fig. 2). The skin flap is then elevated in an opposite direction to which it has sagged, that is, the flap is elevated in all parts and pulled gently over the ear toward Darwin's tu-
Photographs are taken of the front and both sides of the face, while laughing and relaxed. The photographs of movement of the face are of great importance to detect possible weakness of the facial nerve and to have a picture of muscle function. Together with the patient these photographs are carefully analyzed and any asymmetries, such as a difference of the eyebrow heights or a deeper nasolabial fold on one side, are discussed. The features of the skin and the visible signs of aging due to diminished skin elasticity are shown; but also crows feet, frown lines, and vertical lines on the lips or deformities of the eyelids, such as fat bags, are pointed
Downloaded by: National University of Singapore. Copyrighted material.
FIBRIN GLUE IN FACE LIFTS-Flemming
Downloaded by: National University of Singapore. Copyrighted material.
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Figure 3. A: A 70-year-old woman before; after a face lift; C: 11 years postoperatively.
3 weeks
FIBRIN GLUE IN FACE LIFTS-Flemming
Prernedication and Preparation
When the patient arrives for surgery, the hair is saturated with an alcoholic solution, an area of approximately 3 cm is shaved over and behind the ear, and the rest of the hair is tied in tufts (Fig. 4). Once blood pressure is taken, a premedication of
Figure 4.
Preparation of the hair before surgery.
50 mg promethazine hydrochloride (Atosil),0.5 mg atropine, and 15 mg pentazocine (Fortral) is given. Intravenous infusion of physiologic saline solution is given. Blood pressure and heart rate are monitored continuously. Local Anesthesia
For local anesthesia we use a solution of 0.5% lidocaine (5 mg) with epinephrine (0.01 mg) for 30 or 40 cm3 on each side. This solution is given as an intracutaneous injection along the incision lines and subcutaneously in the area to be undermined. Disinfection is done using a povidone-iodine alcohol solution. A sterile towel is fixed with sutures on the posterior side of the shaved area. Operative Technique
We prefer the double S incision described by Pitanguy.13It starts in the temple within the hairline, curves downward crossing the rim of the tragus, passes around the earlobe to the posterior concha1 surface, and ends in the postauricular area of the scalp. The marking of the double S incision is done with brilliant green (Fig. 5). The skin is incised along the marked line. The
Figure 5. Marking of double S incision and direction of skin reposition.
Downloaded by: National University of Singapore. Copyrighted material.
out. The importance that the patient attaches to each of them is noted and explanations are given concerning what can and cannot be corrected by face lift. The patient must understand that rhytidectomy corrects basically the skin tension and that only the folds caused by laxity of the skin will be gone after surgery but the fine, deep wrinkles often due to sun exposure will not be removed, only ameliorated. Such wrinkles require dermabrasion or chemical peel. Likewise, the deep nasolabial fold must be corrected by additional injections of collagen. The incisions are marked on the photographs, even the necessary undermining of the skin flap. The expected surgical result is once more discussed with the patient. The patient's health must be good and under the supervision of an internist. Women should not be menstruating or within 10 days of menstruation. The patient should avoid stress and relax the week before surgery. The hair should not be cut short and must be washed the day prior to surgery.
temporal and retroauricular part of the incision is made with the scalpel blade directed forward to preserve the hair follicles in the posterior wound margin. Undermining is done subcutaneously using first the scalpel and proceeding with scissors. In the area above the zygomatic arch, the level of undermining is beneath the temporal fascia. Care must be taken in the area beneath the nonhair-bearing skin over the temple to avoid damage to the temperofrontal branch of the facial nerve. Dissection should therefore be continued superficially in this region. Undermining in the face and neck are then completed. When necessary the whole neck is undermined to make it possible to pass from one side of the face to the other. The next step is to determine whether further procedures (elevation of the SMAS or fat removal) are necessary. We perform these after the skin is completely undermined, fixing the SMAS with one key suture and fibrin glue. If fat removal is necessary, liposuction is used. An accurate hemostasis is very important, even when the fibrin glue is used to avoid postoperative hematoma. The new skin tension is marked first in the facial region by pulling the undermined skin Figure 7. Key suture in the temple area. gently in the direction of the Darwin process (Fig. 6). The skin is incised until the marked point and a key suture is taken in the region above the ear (Fig. 7). The overlapping skin in the temporal region is then marked with brilliant green and excised. The same procedure is followed in the netck where the skin is gently pulled in the direction of the Darwin process (Fig. 8). Once the skin to be removed has been marked, it is then incised and a key suture is taken in the mastoid region. The overlapping skin is excised after the amount to be removed has been marked. The remaining skin is then pulled over the ear without tension and the excessive skin is marked and then excised (Fig. 9). The fibrin glue is applied after hemostatic stability has been ascertained. We use a long-button cannula to reach the whole undermined area without damaging the tissue. We start from the temporal region and move toward the face and neck applying first the thrombin and then the fibrinogen (Fig. 10). Using gentle pressure on the face and neck the surplus of fibrin glue is pressed out (Fig. 11). It is important to use only a thin layer of fibrin. Care must be taken not to press too hard on the skin to avoid necrosis. Suturing of the skin completes the intervention. Dressing and Postoperative Care
1
Figure 6. Mark~ngof the amount of sk~nthat needs to be resected In the temple region.
Povidone-iodine ointment is put on gauze and placed over the sutures and a circular head dressing is with a very light pressure. After surgery, the patient relaxes in bed in an
Downloaded by: National University of Singapore. Copyrighted material.
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Figure 8. Marking of the amount of skin that needs to be resected in the mastoid region.
Figure 9. the ear.
Figure 10. Application of fibrin glue with a long button cannula.
Marking of excessive skin before and behind Figure 11. The surplus of fibrin glue is pressed out.
Downloaded by: National University of Singapore. Copyrighted material.
FIBRIN GLUE IN FACE LIFTS-Flemming
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Complications
Hematoma The most common complication of rhytidectomy is a postoperative hematoma. Large hematomas must be pressed out to avoid infections or necrosis of the skin that cannot be nourished from the underlying tissue. Small hematomas become organized, leaving hard regions that disappear after 6 months or so. Prevention requires meticulous hemostasis. The application of fibrin glue helps a good deal. In fact, since 1976 when we first used the fibrin glue in face lifts, we have seen only one really large hematoma, 36 hours after surgery that required a return to the operating theatre to close the bleeding vessel (Fig. 13). Infections Infections occur very seldom in the face, especially as a result of cosmetic surgery in healthy patients. Necrosis of the Skin Irritation of the skin is always a symptom of bad nutrition of the skin flap and is fortunately very rare. It may occur: 1. by putting too much tension on the flap 2. by dissecting the flap in a plane that is too thin 3. by leaving a too thick layer of fibrin glue 4. by putting too much pressure on the skin flap when extra fibrin glue is pressed out (Fig. 14) 5. by leaving a large hematoma untreated 6. following infections.
Figure 12. A 40-year-old patient 1 day after face lift.
Nerve Injury Facial Nerve. A lesion of the facial nerve is most irregular because of its anatomic position in the parotid gland. The dissection of the skin flap is made above the parotid capsule, threatening only the frontal branch of the facial nerve during dissection of the temple region and the marginal mandibular branch undermining the skin in the mandibular region. Although it is a very rare complication, if the nerve is cut there will be no spontaneous regeneration and it will be impossible for the patient to move the damaged part of her face. Injury to the nerve is avoidable if the flap is undermined in the correct plane. Auricular Nerve. Damage to the auricular nerve will lead to a persistent insensibility of the auricle. This complication also occurs very rarely but is more common than lesions of the facial nerve. The risk occurs when the posterior border of the sternocleidomastoid muscle is dissected too deeply.
Downloaded by: National University of Singapore. Copyrighted material.
upright position cooling the face with ice packs for 1 to 2 hours until the blood pressure has stabilized and a normal condition of the patient is assured. Then the patient may return home. The patient should not stay in bed but behave as usual, of course, without moving the operated area. Walks of 95 to 1 hour twice a day are recommended. Gymnastic or other sports will be followed by an increase in the blood pressure and must be avoided, as well as moving the face and neck, in order to prevent hematoma (no laughing, speaking, eating hard food for 5 days). The first day analgesics may be given if required. There is no other medication, especially no antibiotics. By the first operative day the patient should be pain free. The dressing is changed at this time (Fig. 12) and removed on the fourth day. Only a spray dressing is used to protect the sutures. On the fifth day the hair can be washed. The stitches are removed between the sixth (preauricular)and 12thday. Postoperative photographs are taken at 2 weeks. We advise the patient to massage the scars around the ear lobe and the retroauricular region with Contractubex and to see his or her doctor the moment the scars seem to become harder. Generally we see the patient 6 months to a year after surgery for a last check-up and to take photographs.
Figure 13. A: A 63-year-old patient before face lift; B: 11 months after surgery followed by complication of a large hematoma.
-
-
Damage to the Parotid Gland
Injury to the glandular lobules is a rare complication that is followed by a parotid fistula. X-ray treatment is necessary to close the fistula.
i
Deformity of the Ear Lobe Giving too much tension on the skin flap in the auricular region will result in an ear lobe that is too long. Using fibrin glue will provide this deformity. Bad Scarring The causes of unpleasant scars are: 1. too much tension 2. healing by secondary intention (after press-
3. a disposition for hypertrophic scars. Bad scarring is the most common complication and occurs mostly in the region of the mastoid and the ear lobe. It very seldom occurs before the ear or in the hair. Figure 14. Skin necroses behind the ear due to too much pressure on the skin flap pressing out the surplus of fibrin glue.
Hair Loss Hair loss may occur for following reasons:
Downloaded by: National University of Singapore. Copyrighted material.
FIBRIN GLUE IN FACE LIFTS-Flemming
FACIAL PLASTIC SURGERY Volume 8, Number 1 January 1992
Haemocomplettan HS and Topostasin. However, there are sets of fibrin glue available ready for application with double canula or as a spray set. The sets are very helpful in sealing small areas or skin flaps. However, the sets are not adequate for sealing the already fixed skin flap in face lifts; the double canula produces an immediate clotting of the glue and so it Allergic Reaction is not sure that every angle of the wound can be By using the fibrin glue there is a possibility of reached with a thin fibrin film. For this purpose the immediate allergic reactions type I or late allergic spray seems to be better. The disadvantage of the reactions type 11. This complication is very rare and spray is that it has to be applied from a distance of 10 can be treated successfully with immediate cortico- to 20 cm from the area to be sealed. This is impossteroid (250 mg prednisolone) on the first and sec- sible after an extensive undermining passing from ond days and additional application of antihista- one side to the other. In less extensive undermined regions, fibrin spray may be used before key sutures mines for 1 week. above the ear and in the mastoid region are placed. We think there is more disadvantage than advantage proceeding this way. DISCUSSION In our hands the use of fibrin glue in face lifts gives not only the advantage of a shorter operating time or a reduction in drains, but also minimal postoperative swelling, a quicker recovery time, and a recovery that is, in general, free of complications. Because we are performing the face lift using local anesthesia and as an outpatient procedure, it is extremely important not to have postoperative complications, especially no hematoma. To achieve this effect, all small vessels and capillaries must be closed with the seal, mainly those that are not bleeding during the operation due to the vasoconstrictive effect of epinephrine added to the local anesthesia; if only a small area is not reached by the glue, bleeding may occur in this region, when the vasoconstrictive effect is over. A hematoma will be the result; therefore we prefer to apply the fibrin glue with a long button canula. This is logically preceded by undermining of the skin, meticulous hemostasis, and fixing of the flap in normal skin tension with two key sutures. With the long button canula, we are sure to reach the whole undermined area without damaging the tissue. We start from the temporal region and move toward the face and neck, applying first thrombin and than the fibrin glue. Using gentle pressure on the face and neck, the surplus of the fibrin glue is pressed out. It is important to use only a thin layer of fibrin glue. Care must be taken not to press too hard to avoid skin necrosis. As already discussed we use
REFERENCES 1. Grey EG: Fibrin has a hemostatic in cerebral surgery Surg Gynecol Obstet 21:452-454, 1915 2. Cronkite PE, Lozner EL, Deaver JM: Use of thrombin in skin grafting. JAMA 124:976-978, 1944 3. Matras H: Die Wirkungen verschiedener Fibrinpraparate auf Kontinuitatstrennungen der Rattenhaut. Osteer Z Stomat 67:338, 1970 4. Matris H, Dinges HE Lassmann H, Mamoli B: Zur nahtlosen interfaszikularen Nerventransplantation im Tierexperiment. Wien Med Wochenschr 122:517, 1972 5. Matras H, Braun E Lassmann H, et al: Plasma clot welding of nerves (experimental report) J Maxillofac Surg 1:236, 1973 6 . Matras H, Chiari FM, Kletter G, Dinges HP: Zur Klebung von MikrogefiiPanastomosen. Bericht der 13. Jahrestagung der Deutschen Gesellschaft fiir plastische und Wiederherstellungschirurgie. Sept. 1975. ~ i u t t ~ a rGeorg t: Thieme Verlag, 1977, v 57 7. spangier HP: Gewebeklebung und lokale Blutstillung mit Fibrinogen, Thrombin und Blutgerinnungsfaktor XIII. Wien Klin Wochenschr 88 (Suppl 49):l-18, 1976 8. Piechotta FU, Flemming I: Fibrinogen adhesive in plastic surgery In: Plastic and Reconstructive Surgery of the Head and Neck. The Third International Symposium, Vol 1: Aesthetic Surgery. New York: Grune & Stratton, 1981, pp 195-198 9. Piechotta FU, Flemming I: The maximization of wound healing with fibrin glue. Aesthetic Plast Surg 7%-82, 1983 10. Minazzer H: Fibrin sealing: Physiology and Biochemical Background. Facial Plast Surg 2:291-295, 1985 11. Red1 H, Schlag G: Principles of fibrin sealant and its mode of application. Facial Plast Surg 2:315-326, 1985 12. Flemming I: Surgery of the aging face, the face lift. Facial Plast Surg 2:363-370, 1985 13. Pitanguy I: Aesthetic Plastic Surgery of Head and Body. Berlin: Springer-Verlag, 1981
Downloaded by: National University of Singapore. Copyrighted material.
1. Damage done to the hair roots during dissection of the skin flap. 2. Too much tension on the hair-bearing skin flap 3. Tying the sutures too tightly. 4. As a result of skin necrosis.
