Use of Kaolin-impregnated Gauze for Improvement of Intraoperative Hemostasis and Postoperative Wound Healing in Blepharoplasty

Upper eyelid surgery involves incisions, excision of skin, and often a portion of the orbicularis muscle. The procedural variables, including incisional modality and the patients’ hemodynamic profiles, result in unpredictable hemostasis. The eyelids have relatively small caliber vessels, but a rich plexus of vascularity. Hemostasis is a critical component of a successful eyelid surgery and postoperative safety. In the case of eyelid surgery, orbital hemorrhage with vision loss is estimated to happen 1 in 2,000 to 1 in 25,000 cases.1 Hemostasis can be achieved by mechanical, thermal, and/or pharmacological means. Mechanical methods include placing direct pressure over the wound or suture ligation of distinct vessels. Mechanical methods are beneficial in obtaining hemostasis, but may prolong surgical time and induce unwanted effects. Ligation sutures introduce foreign material and may alter wound healing. Thermal-based methods employ the use of heat to denature hemorrhaging tissues and to seal vessels. Risks of thermal modalities include patient injuries, user injuries, fire, and electromagnetic interference with other medical equipment.2 By causing local tissue destruction, thermal-based modalities may alter wound healing, causing a reduced functional and/or cosmetic result. Moreover, devitalized tissue may increase risk of infection. Pharmacological agents, such as epinephrine, vitamin K, and protamine, have been used to improve hemostasis. Systemic effects of pharmacological agents may discourage their use. Without proper hemostasis, a hemorrhage and/or hematoma may develop, resulting in wound dehiscence, further surgery, or other unwanted sequalae. Kaolin is a naturally occurring aluminum silicate mineral derived from clay. It has been used homeopathically to promote wound healing and reduce scar formation for centuries. Kaolin activates clotting factor XII (Hageman factor) when exposed to plasma, thus activating Factors XII, XI, and prekallikrein A novel hemostatic dressing called QuickClot® Combat Gauze (Z-Medica, Wallingford, Connecticut) is a non-woven medical gauze of 50 percent polyester and 50 percent rayon impregnated with kaolin. The gauze is impregnated with the inert kaolin mineral without use of animal or human proteins; no allergic reactions have been reported.3 Kaolin-impregnated gauze has been shown to be efficacious in stabilizing arterial hemorrhages in swine models.4 In addition, studies show kaolin-impregnated gauze to be safe and effective in controlling hemorrhage in extremity and abdominal sites.5-8 Most recently, kaolinimpregnated gauze has been shown to achieve hemostasis in femoral artery access sites during percutaneous coronary interventions.1 Kaolin-impregnated gauze is the “only approved hemostatic agent for all the United States Armed Forces,” and is given to the frontline soldiers in first aid kits.9 Intrigued by its applications in situations requiring hemostasis at various body sites, this study was conceived to examine the application of kaolin-impregnated gauze to control intraoperative bleeding and promote wound healing in eyelid surgery. While excessive bleeding is uncommon in eyelid surgery, the rare catastrophic outcome of visual loss motivates us to search for modifiable features to improve hemostasis without compromising surgical outcomes. Further, improved immediate postoperative cosmesis is something patients routinely seek, but is difficult for surgeons to provide.