|Use of tissue sealants in face-lifts: a metaanalysis
|Por YC, Shi L, Samuel M, Song C, Yeow VK
The review found no statistically significant benefit for use of tissue sealants such as fibrin tissue adhesives and platelet-rich plasma in reducing postoperative drainage, ecchymosis and oedema after face-lift surgery. In view of the limited evidence and limitations in the review process, the authors’ overall conclusions should be treated with caution.
To evaluate the efficacy of tissue sealants such as fibrin tissue adhesives and platelet-rich plasma in reducing postoperative drainage, ecchymosis and oedema after face-lift surgery.
MEDLINE (from 1966 to May 2007), EMBASE (from 1974 to May 2007) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched; search terms were reported.
Prospective randomised controlled trials (RCTs), which included controlled clinical trials, meta-analyses and reviews of RCTs of use of tissue sealants such as fibrin tissue adhesives and platelet-rich plasma in face-lift or rhytidoplasty surgery in humans of all ages were eligible for inclusion. The primary outcome was postoperative drainage from the wound bed after 24 hours. Secondary outcomes were postoperative ecchymosis and oedema seven to eight days after surgery.
The tissue sealants and procedures used in the included RCTs were Tisseel (vertical U incision, SMAS plication), Beriplast P (1mL) (subcutaneous SMAS placation) and autologous platelet-rich plasma (7mL to 8mL) (deep-plane face-lift). Participant ages, where reported, ranged from 42 to 72 years.
The authors did not state how many reviewers performed the selection.
Assessment of study quality
Criteria used for the assessment of methodological quality were: ethical approval, randomisation, blinding, allocation concealment, intention-to-treat (ITT) analysis, loss to follow-up and volume and type of sealant used.
The authors did not state how many reviewers performed the quality assessment.
Data were extracted in order to calculate mean differences or risk ratios (RRs) with 95% confidence intervals (CIs).
The authors did not state how many reviewers performed the data extraction.
Methods of synthesis
Weighted mean differences (WMDs) and 95% CIs were pooled with a random-effects model due to the large variation in effect measurement in the included studies. Forest plots were generated. Pooled relative risks (RR) and 95% CIs were calculated with a random-effects model for ecchymosis and for oedema. Between-study heterogeneity was determined using Χ2 and I2 tests.
Results of the review
Three relevant RCTs were identified (n=58, range eight to 30). All three studies were randomised, blinded, had ethical approval and reported no loss to follow-up. Two RCTs performed an ITT analysis. Only one RCT reported concealment of allocation.
Pooled analysis showed a non-significant trend for tissue sealants to reduce postoperative drainage after 24 hours (WMD -15.81, 95% CI -34.49 to 2.88, I2 = 64.2%; two studies) and ecchymosis at seven to eight days (RR 0.37, 95% CI 0.12 to 1.11, I2 = 0%; two studies) with no significant effect for oedema at seven to eight days (RR 0.64, 0.08 to 4.84, I2 = 43.8%; two studies).
There was no statistically significant benefit from use of tissue sealants in face-lift surgery. Tissue sealants may be useful for patients at high risk of haematoma and ecchymosis formation.
The review addressed a well-defined question in terms of participants, interventions, study design and relevant outcomes. Relevant databases were searched. It was unclear whether language restrictions were applied, unpublished studies were considered and relevant articles were handsearched; if not, some studies may have been missed. Study quality was assessed using suitable criteria. Although study quality was assessed, no actual details were given about how randomisation was performed and study quality results were not discussed in relation to the pooled results. The studies were within-patient comparisons and no details were given about comparator treatments (other than being described as "no sealant" on forest plots), which made it difficult to interpret and compare the RCT results. The authors did not report any efforts made to reduce error and bias in the review process (such as independent duplicate screening). Relevant study details were reported, but no details of the gender of the included participants were provided. Statistical heterogeneity was assessed and there was evidence for heterogeneity with some outcomes. The statistical method used for the meta-analysis of the RCTs seemed appropriate, but some details were not given.
The very small number of studies with low numbers of participants, some potential limitations that arose from the review process and the limited reporting of some aspects of the review mean that the authors’ overall conclusions should be treated with caution.
Implications of the review for practice and research
Practice: The authors concluded that it was safe to perform face-lifts using drains alone. They suggested use of tissue sealants for patients at high risk of haematomas, such as those with agitation, hypertension and coagulopathy and for male face-lift patients.
Research: The authors identified a need for further prospective randomised studies with larger sample sizes. They suggested that it was important to pool the results of all studies, however small.
Por YC, Shi L, Samuel M, Song C, Yeow VK. Use of tissue sealants in face-lifts: a metaanalysis. Aesthetic Plastic Surgery 2009; 33(3): 336-339
Subject indexing assigned by NLM
Ecchymosis /prevention & control; Edema /prevention & control; Exudates and Transudates /metabolism; Fibrin Tissue Adhesive; Hematoma /prevention & control; Humans; Platelet-Rich Plasma; Postoperative Complications /prevention & control; Randomized Controlled Trials as Topic; Rhytidoplasty /adverse effects /methods
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.