According to the American Society of Plastic Surgeons cohort study, facial plastic surgery is steadily increasing with the growth of the gross domestic product [1]. In particular, the rhinoplasty rate is second only to the rate of minimally invasive cosmetic surgeries [1]. Although rhinoplasty is considered a cosmetic surgery, complications such as edema and ecchymosis frequently occur after the procedure. Such complications aggravate patient discomfort and delay a return to daily life. Consequently, various therapeutic methods such as steroids, intraoperative hypotension, intraoperative cooling, head elevation, piezosurgery, and tranexamic acid have been tested to reduce morbidities after rhinoplasty [2-5]. Some of these treatments are known to reduce postoperative morbidities, but some remain controversial [4]. Despite considerable effort, edema and ecchymosis are still frequent after rhinoplasty, and are a major cause of deterioration in patient quality of life. Moreover, severe edema and ecchymosis can increase scarring and alter intended surgical outcomes [6,7].

Surgical method characteristics can also affect postoperative morbidities. The surgical techniques used in rhinoplasty are classified into open (external) rhinoplasty and closed (endonasal) rhinoplasty [8]. Endonasal rhinoplasty is associated with low morbidities and results in a natural appearance. This outcome is achieved by retaining the original shape of the nose and preserving major cartilage architectures. However, endonasal rhinoplasty has disadvantages as it is a difficult surgical technique, provides limited visibility, and allows inadequate accessibility to cartilage. On the other hand, open rhinoplasty is a more straightforward method for accessing cartilage, and is preferred for highly complex surgeries and educational purposes. However, open rhinoplasty also has disadvantages including a high complication rate and delayed recovery time. High postoperative morbidities might be expected because soft tissue bleeding is inevitable due to the nature of external rhinoplasty. In particular, it is known that osteotomy, which is frequently performed in rhinoplasty, increases morbidities such as edema and ecchymosis [9]. Because open rhinoplasty and osteotomy cannot be completely avoided, methods to reduce postoperative morbidities more effectively are needed.

Fibrin sealant (FS) is a plasma cryoprecipitate-based sealant that consists of two components: human sealer protein and human thrombin [10]. The invention of this sealant was based on the development of the fibrin network that represents the final phase in the blood coagulation process. Morawitz [11] was the first to describe the physiological mechanism of FS. Since it was invented, FS has been widely used for suture support, tissue adhesion, and hemostasis. Several studies have shown that FS reduces postoperative bleeding and ecchymosis by sealing capillary vessels, which in turn lessens postoperative swelling by promoting wound adhesion and minimizing dead space [12,13]. Recently, attempts were made to test the efficacy of FS to reduce postoperative complications after rhinoplasty. Consequently, the purpose of this meta-analysis was to investigate whether the application of FS could reduce the severity of complications such as edema and ecchymosis after rhinoplasty. We reviewed randomized controlled trials (RCTs) that compared the rate of complications after rhinoplasty between patients who were treated with FS, and those who were not.

Various studies have attempted to identify the benefits and side effects of FS application in otolaryngology. A previous study of 100 parotidectomy patients confirmed that application of FS caused very few side effects [17]. Another report showed that FS could replace drainage in thyroidectomy [18,19]. Other surgical uses for FS include reduction of the transfusion rate in femoral neck fractures and knee surgeries [20,21]. An additional study confirmed that FS reduced the risk of leakage in laparoscopic common bile duct incision [22].

Postoperative edema and ecchymosis are the most common side effects of rhinoplasty. Meticulous techniques and standard hemostasis are crucial and cannot be replaced by hemostatics. However, the surgical field of rhinoplasty is very narrow and commonly involves soft tissue and bony destruction. These features allow surgeons performing rhinoplasty to use an applicable hemostatic method. The main purpose of this study was to evaluate whether FS could reduce complications frequently occurring in patients who undergo rhinoplasty. We analyzed three RCTs that studied the effects of FS on the rate of postoperative complications.

The adhesive, sealing, and hemostatic properties of FS may be useful in rhinoplasty. FS can reduce capillary bleeding and serous exudate at the operative site. Two of the three studies included in this meta-analysis demonstrated an advantage associated with FS application on day-1 after rhinoplasty. An FS effect on the reduction of complications was observed only during the initial few days after surgery and not at 1-week postoperative. This outcome could be due to the gradual recovery over time of patients without FS application. The results from this study showed that the application of FS reduced early capillary bleeding and exudate. Considering that patient discomfort is severe in the initial period just after surgery, we expect that the use of FS will be acceptable. An additional advantage for patients is a possible early return to daily life and work. Furthermore, it is encouraging that the three studies analyzed in this meta-analysis did not report any serious side effects, such as allergic reactions to FS.

Our study has several limitations. First, the number of papers and participants in this meta-analysis is small, and the sample size is skewed toward a single paper. Second, the three RCTs have distinct designs, and some of them deviate slightly from the RCT standard. Thus, interpretation requires prudence. However, to the best of our knowledge, this is the first meta-analysis to assess the effects of FS in preventing rhinoplasty-associated morbidities, including ecchymosis and edema.

In conclusion, FS significantly reduced 1-day postoperative complications such as ecchymosis and edema in patients who underwent rhinoplasty. Further large-scale studies on the efficacy of FS to reduce surgical complications after rhinoplasty are needed.