Aesth Plast Surg DOI 10.

1007/s00266-012-9978-y

ORIGINAL ARTICLE

AESTHETIC

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

lica Maria Schettino Diogo Franco Ange o Medeiros Tavares Filho Talita Franco Joa 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 properties that speed up healing, hemostasis, and adhesiveness, in addition to growth factors. Through an established protocol, 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 autologous use of thrombin and PPP to foster adhesion between an abdominal dermoadipose ap and the aponeurotic surface 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 incidence 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 rst POD in the Plasma group. There was no reduction in the incidence of seroma in these patients. Similarly, age and BMI did not inuence these outcomes.

Conclusion The PPP fostered adhesion between the abdominal dermoadipose ap and the aponeurotic surface only on the rst POD and had no inuence 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 instructions 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 complication [13], 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 gure 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 scientic novelties, brin glue is a promising option for tissue adhesion, with reduced postoperative edema and the need for drains. It also helps reduce the occurrence of liquid buildup, seroma, and hematoma [5]. It is usually produced through plasmapheresis, using a pool of known donors, while thrombin is animal (bovine) in origin. Inconvenient aspects of brin 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: angelicaschettino@yahoo.com.br A. M. Schettino Marcilio Dias Navy Hospital, Rio de Janeiro, Brazil F. S. Vendramin , Bele m, Para , Brazil Federal University of Para

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(as the origin of this substance is bovine), and viral transmissions (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 [79]. The purpose of this study was to demonstrate the use of platelet-poor plasma (PPP), also known as brin glue, as an adhesive element in abdominal dermolipectomies and analyze its action and its effect on the incidence of seroma among these patients.
Fig. 2 Application of activated plasma to the aponeurotic surface

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 rst 20 patients underwent surgery using PPP in the supraaponeurotic surface, after resectioning excess skin and immediately before positioning the dermoadipose ap (Plasma group). The other 20 patients underwent abdominal 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 maximum 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 laboratory test results. The average volume on the rst postoperative day (POD1) in the Plasma group (P group) was 53.2 and 105.1 ml on the POD2, with this difference being signicant (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 signicant reduction 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 statistically signicant ndings between these data for either of the two groups (Tables 4, 5).

Fig. 1 Activation of plasma by thrombin

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Aesth Plast Surg Table 1 Descriptive statistics of serohematic liquid volumes (ml) by POD Descriptive statistics Plasma group N Mean Standard deviation Minimum Median Maximum Control group N Mean Standard deviation Minimum Median Maximum p-value by the Mann-Whitney test (comparison between the groups) 20 103.7 65.8 13.0 91.5 248.0 0.004 20 105.2 63.9 35.0 85.0 273.0 0.441 19 78.4 42.9 30.0 64.0 178.0 0.763 13 68.2 39.5 18.0 64.0 150.0 0.339 9 57.0 17.8 35.0 55.0 90.0 0.159 4 52.3 9.9 45.0 49.0 66.0 1.000 20 53.2 26.7 10.0 62.0 102.0 20 105.1 101.8 20.0 75.0 450.0 17 70.5 38.1 14.0 67.0 185.0 11 50.5 23.8 20.0 50.0 107.0 5 36.0 24.1 0.0 45.0 62.0 2 60.5 29.0 40.0 60.5 81.0 1 POD 2 POD 3 POD 4 POD 5 POD 6 POD Plasma Control Total Table 3 Incidence of seroma in the Plasma and Control groups Group Total n 20 20 40 % 100.0 100.0 100.0 Without seroma n 13 16 29 % 65.0 80.0 72.5 Seroma n 7 4 11 % 35.0 20.0 27.5 p-value by the test v2 0.288

Bold values indicate the percentual of patients that did not have seroma

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 [79, 1114]. 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, 1418]. The protocol used in this study produces outcomes similar to those found by the main authors in this eld and can isolate both plasma fractions at the same time. Furthermore, it is also possible to isolate and produce the thrombin that is used to activate the plasma. This production 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 brin glue and is, in fact, known by this name by several authors [9, 1922] as it is endowed with a sealing action similar to industrially produced glue. The use of autologous

Table 2 Comparison between the POD1 and other days, among days and between groups Descriptive statistics Plasma group N Mean Standard deviation Minimum Median Maximum p-value (Wilcoxon test) Control group N Mean Standard deviation Minimum Median Maximum p-value by the Wilcoxon test (comparison of days with a POD1) p-value by the Mann-Whitney test (comparison between the groups) 20 1.5 80.2 -155.0 1.5 190.0 0.955 0.064 19 -26.8 91.7 -218.0 -15.0 165.0 0.191 0.035 13 -29.0 84.7 -156.0 -25.0 135.0 0.249 0.325 9 -42.0 75.5 -175.0 -32.0 55.0 0.161 0.947 4 -33.5 61.8 -97.0 -44.0 51.0 0.465 0.355 20 51.9 94.4 -45.0 29.5 348.0 0.006 17 17.7 37.9 -51.0 14.0 96.0 0.072 11 -9.2 25.4 -50.0 -10.0 40.0 0.182 5 -30.6 52.4 -102.0 -35.0 38.0 0.225 2 -23.0 2.8 -25.0 -23.0 -21.0 0.180 2 POD 3 POD 4 POD 5 POD 6 POD

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Aesth Plast Surg Table 4 Descriptive statistics on age and BMI by seroma incidence in the Control group Statistics Seroma No (n = 16) Age (years) Mean Standard deviation Minimum Median Maximum BMI (kg/m2) Mean Standard deviation Minimum Median Maximum *Mann-Whitney test Table 5 Descriptive statistics on age and BMI by seroma incidence in the Plasma group Statistics Seroma No (n = 13) Age (years) Mean Standard deviation Minimum Median Maximum BMI (kg/m2) Mean Standard deviation Minimum Median Maximum *Mann-Whitney test 39.4 11.6 23.0 35.0 60.0 23.2 2.3 18.1 23.9 26.4 Yes (n = 7) 45.4 9.6 31.0 47.0 60.0 23.4 2.0 20.7 23.6 25.5 0.877 0.211 p-value* 41.9 8.9 33.0 38.0 59.0 23.4 2.1 19.5 23.9 26.1 Yes (n = 4) 41.8 15.4 28.0 39.5 60.0 23.4 2.1 21.6 23.3 25.6 0.963 0.750 p-value*

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 monitoring the daily aspiration drain debit. The incidence of seroma 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 signicant 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

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applied with thrombin up to 4 h after it was made. The importance of the plasma temperature is related to its stability 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 inuence the incidence of seroma. There are some rmly established techniques for reducing seroma in abdominoplasty, 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 resectioned. 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, sufcient 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 production 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 eld of medicine, making better use of substances that speed up healing and make ap adhesiveness a reality.

group, the BMI did not inuence 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 outcomes 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.
Conict of interest The authors have no conict of interest to disclose

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