A simple technique for bloodless surgery

The need for good haemostasis is felt in surgery in general, and in plastic and aesthetic surgery in particular. Optimal haemostasis favours the ongoing search for ever-greater precision in surgical operations and facilitates the early phases of the scarring process. In addition, it shortens healing times. In the literature that we consulted, we found a proposal for biological supplementation with platelet-enriched plasma obtained after centrifugation of about 60 ml of autologous whole blood for between 15 and 30 minutes. At the end of a face-lifting operation, the enriched plasma is injected under the flaps obtained by blunt dissection, with a view to reducing post-operative bleeding, thereby minimising swelling and bruising (1).
In an attempt to work out a technique that could facilitate haemostasis in the operating phase, and not only in the post-operative period, we experimented with a biological preparation that can be produced more easily than enriched plasma: autologous serum obtained by means of high-velocity centrifugation, diluted in a solution containing, or not containing, a local anaesthetic. Preparation is simple and rapid. A sample of blood is placed in one or more 6 ml test tubes, without additives, and centrifuged for 6-15 minutes. We usually add this autologous serum to an anaesthetic solution containing epinephrine, in variable proportions according to the type of anaesthesia required and the type of operation to be performed. The ratio used in transconjunctival and upper blepharoplasty, for instance, is1:4.
The results appear to be noteworthy. Tissue incision and dissection have been greatly facilitated by the almost total absence of bleeding. Swelling and ecchymoses in the immediate post-operative phase have been markedly reduced (fig. 1). In some of our tests, we have compared the administration of local anaesthetic alone with that of the anaesthetic supplemented with autologous serum in the same patient, for example in blepharoplasty. A significant difference was noted, both during the operation and in the post-operative period. When the supplemented solution was used, haemostasis proved to be immediate.   
We feel it is plausible that this improvement in haemostasis is due to the local addition of coagulation factors present in the autologous serum (prothrombin, thromboplastin, calcium and factors VII, VIII, IX, XI, XII) to the intrinsic and extrinsic pathways. Further advantages of using serum emerge from a recent report in The Lancet of research conducted by a group of British plastic surgeons (2). In experimental models of wound healing, these authors found that the synthesis of collagen and fundamental substance by skin fibroblasts in the scarring phase was stimulated by the addition of collagen and serum, and that the epithelial cells were activated and assumed a polarised appearance. These effects were not produced by the addition of collagen and plasma. This suggests that, as well as promoting haemostasis, serum exerts a regenerative effect on tissues undergoing scarring.
The technique described may well be refined further and extended to other uses. For example, we  also add autologous serum to the centrifuged fat that is injected during lipofilling (ratio 1:4), and greater dilution ratios are currently being tested. In the future, a simple centrifuge for 6 ml test-tubes is likely to become a standard piece of equipment in many operating theatres.

References

 1) Miller P. J., Constantinides M., Doud Galli S. K. Midfacial effects of the deep-plane facelift. Facial Plastic Surgery 2001; 17 n° 1:  49-56.
 2) Henry G, Li W, Garner W, Woodley DT. Migration of human keratinocytes in plasma and serum and wound re-epithelialisation. Lancet 2003 Feb 15;361 (9357) : 574-6.

The film footage demonstrates each phase of the method, from the high-velocity centrifugation of a small amount of the patient's blood to its practical application in a transconjunctival blepharoplasty operation carried out by means of Timedsurgery. The results three days after upper and lower blepharoplasty operations are shown. The region of the eye-lid, which is critical with regard to bleeding, oedema and ecchymosis, constituted an excellent testing ground for the method. The results also feature a face seen three days after lipofilling.