MARCO ISLAND, FL—Doctors, faced with challenging problems of mending nasal septal perforations, suggested that the use of fibrin glue to hold into place an AlloDerm graft is effective and likely cost-saving.
“The use of fibrin glue for fixation of the acellular human dermal allograft in septal perforation repair is technically less difficult, reduces the length of the procedure, and we believe it reduces graft migration when compared to conventional suturing techniques,” said James R. Parry, DO, a resident in otolaryngology at the State University of New York, Upstate Medical Center in Syracuse.
Dr. Parry described the techniques of the procedure in an oral presentation at the meeting of the Triological Society here, noting that the head and neck surgeon is faced with a delicate procedure while attempting to eliminate the patient’s symptoms by restoring the normal nasal function.
He explained that septal perforations can cause significant morbidity. The symptoms associated with septal perforations include nasal congestion or obstruction, nasal crusting and drainage, recurrent epistaxis, and a whistling sound coming from the nose. In addition to the symptoms related to nasal septal perforations, manifestations of the disease process that caused the perforation also may carry significant morbidity.
Dr. Parry noted that the majority of surgical techniques employed today consist of two basic principles: “The use of internasal mucosal flaps for the insertion of a connective tissue interpostional graft. And that perforation repair can be performed either using a closed endonasal or open technique.”
He elected to use acellular human dermal allograft (AlloDerm) as an interpositional graft between mucoperichondrial flaps. He said previous work has suggested that the AlloDerm grafts have been shown to be effective in the repair of septal perforations.
AlloDerm is an acellular dermal matrix derived from donated human skin tissue supplied by US tissue banks utilizing the standards of the American Association of Tissue Banks and Food and Drug Administration guidelines. Since AlloDerm is regarded as minimally processed and not significantly changed in structure from the natural material, the FDA has classified it as banked human tissue.
Developed by LifeCell Corporation in Branchburg, NJ, AlloDerm is prepared in a multistep process that removes both the epidermis and the cells that can lead to tissue rejection and graft failure, without damaging the matrix. Once the dermal tissue has been decellularized, the final step is preservation. The processed tissue matrix is preserved with a patented freeze-drying process that prevents damaging ice crystals from forming. What remains is a matrix or framework of the natural biological components, ready to enable the body to mount its own tissue regeneration process.
Dr. Parry explained that when a patient receives an AlloDerm graft the material is typically sutured to the septum. “Because the AlloDerm is relatively thick, sewing AlloDerm into place to prevent graft migration can be technically difficult to perform,” he said. “To overcome the challenges presented by traditional suturing we adapted the use of fibrin glue for fixation of the AlloDerm graft.”
Mechanisms of Fibrin Sealant
Fibrin glue has been available commercially in the United States since 1998, when the FDA approved the blood-derived products, also known as fibrin sealants, that are applied topically to help control bleeding. Fibrin sealants can be used to stop oozing from small, sometimes inaccessible, blood vessels during surgery when conventional surgical techniques are not feasible.
The main active ingredient of fibrin sealant is fibrinogen, a protein from human blood that forms a clot when combined with thrombin, another blood protein that facilitates blood clotting. The product works by forming a flexible material over the oozing blood vessel that can often control bleeding within five minutes. Although many surgeons have legally prepared their own fibrin sealants, these locally prepared products are not standardized or consistent, and the available sources of fibrinogen are not virally inactivated.
In his presentation at the Triological Society meeting, Dr. Parry illustrated with a series of drawings how the surgeons at Upstate performed a closed endonasal approach with an endoscopic assist. They used a unilateral, bipedicled internasal flap with AlloDerm as an interpositional graft, using fibrin glue for fixation of the AlloDerm graft.
One cubic centimeter of fibrin glue was applied to both sides of the interpositional graft. The graft was placed between the mucoperichondrial flaps and compressed for five minutes to allow for fixation.
Once the procedure was completed, the patients’ postoperative care involved the use of saline nose spray and antibiotics. Doctors performed endoscopic inspection of the repair site on days 7 and 14. The site was again endoscopically evaluated at six weeks and at three months postprocedure.
“Fibrin glue has been used in many areas of the body, so its success in treating septal perforation is not surprising,” said Robert Kern, MD, Professor of Medicine–Otolaryngology at Northwestern School of Medicine in Chicago. “Its use with AlloDerm in this type of procedure appears novel.” Dr. Kern moderated the session at which Dr. Parry presented his case series.
Dr. Parry reviewed six cases retrospectively in which fibrin glue was used to hold the AlloDerm graft in place in order to close the septal defect. The mean follow-up time for the procedure is three months. Three of the six patients had been involved in previous instances involving nasal trauma. And three of the six patients had previously undergone nasal surgical procedures.
“All six of the patients showed marked improvement or complete resolution of their presenting symptoms. Five of six of the patients had complete closure of their septal perforation,” Dr. Parry said.
He suggested there were several advantages of using the fibrin glue for AlloDerm fixation:
- It is easier to secure the AlloDerm graft than traditional suturing technique.
- It may decrease the likelihood of graft migration.
- The use of fibrin glue compared to conventional suturing decreased the length of the procedure by approximately 30 minutes.
- Fibrin glue may also promote regeneration of injured mucsosa.
“By decreasing operative time use of fibrin glue for fixation is potentially more cost effective than traditional suturing techniques,” Dr. Parry said.
©2007 The Triological Society