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27. Implants and Alloplasts (Nonbreast)
Nima Khosravani, Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surger y, pp. 335–343
BIOMETRICAL IMPLANTS
1. What is the most important clinical aspect of any implanted biomaterial?
A. Ability to visualize on radiographic imaging studies.
B. Cost-effectiveness.
C. Size.
D. Permanence.
E. Weight.
AUTOGRAFTS
2. Which of the following describes a methodology to help reduce inevitable free bone graft resorption and
remodeling?
A. Use of cancellous rather than cortical bone in free bone graft.
B. Placement of greater amounts of graft in recipient site.
C. Fixation of graft under mobile tissue recipient site.
D. Extensive dicing of graft material prior to implantation.
E. Addition of platelet-rich plasma to bone graft.
AUTOGRAFTS
3. What is a relative advantage of using cartilage as an autograft compared to free autologous bone graft?
A. Easier to mold.
B. Does not warp over time.
C. Resorption is rare.
D. More potential donor sources.
E. Lower infection rate.
AUTOGRAFTS
4. What is the most worrisome potential complication of allogeneic graft material placement?
A. Delayed hypersensitivity reaction.
B. Hypercoagulability.
C. Infection.
D. Graft failure.
E. Infectious disease transmission.
ALLOGENEIC MATERIALS
5. Which of the following is a considerable disadvantage of utilizing bi-layered acellular dermal regenerative
templates (Integra)?
A. Cannot be used on wounds greater than 20 cm.
B. Lacks matrix strength.
C. Cost.
D. Difficult to apply.
E. Cause congestion/fluid build-up behind graft.
Chapter 27&Implants and Alloplasts (Nonbreast) 179
ALLOGENEIC MATERIALS
6. Which of the following has become the most commonly placed alloplastic material in aesthetic surgery
(nonbreast)?
A. Stainless steel.
B. High-density porous polyethylene.
C. Vitallium alloy.
D. Titanium alloy.
E. Hydroxyapatite.
ALLOGENEIC MATERIALS
7. Which of the following is an important consideration pertaining to high-density porous polyethylene
(Medpor) implants?
A. Has a low fatigue tolerance compared to other implants.
B. Difficult to stabilize.
C. High propensity to resorb.
D. Is very radiodense.
E. Must soak in antibiotic solution prior to placement.
ALLOGENEIC MATERIALS
8. Particularly with regard to aesthetic surgery, which of the following is a substantial disadvantage of using
hydroxyapatite in the facial skeleton?
A. Reports of high inflammatory burden on surrounding soft tissue.
B. High rate of infection.
C. Very difficult to remove.
D. High resorption rate.
E. Does not allow ingrowth of host tissue.
ALLOGENEIC MATERIALS
9. Which of the following is considered a potential advantage of silicone facial implants compared to other allo-
plastic material types?
A. Implant infections easily managed nonsurgically.
B. Allows in-growth of host tissue.
C. Becomes incorporated into facial skeleton.
D. Easily removed.
E. Hydrophilic nature.
180 Part VI&Adjuncts to Aesthetic Surgery
Answers
BIOMETRICAL IMPLANTS
1. What is the most important clinical aspect of any implanted biomaterial?
D. Permanence.
Although there are a number of important ideal properties to consider of any implanted biomaterial
(Box 27.1), the most important clinical aspect of an implanted biomaterial is its permanence, as this will
determine the functional long-term relationship between the host and the implant.
BOX 27.1 IDEAL PROPERTIES FOR GENERIC BIOMATERIAL
Chemically inert
Biocompatible
Nonallergenic
Noncarcinogenic
Cost-effective
Sterilizable
Easy to handle
Radiopaque
Ability to stabilize
REFERENCE
1. Rubin PJ, Yaremchuck MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive
and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg 1997;100:1336
1
AUTOGRAFTS
2. Which of the following describes a methodology to help reduce inevitable free bone graft resorption and
remodeling?
C. Fixation of graft under mobile tissue recipient site.
Although all free bone grafts do inevitably undergo variable degrees of resorption and remodeling, there are
a couple of techniques which can help maintain the volume of grafted material after placement. Cortical
grafts have been shown to maintain their volume significantly better than their cancellous bone graft
equivalents
1
and fixation of bone grafts under mobile recipient tissues reduces resorption rates.
1
REFERENCE
1. Ozaki W, Buchman SR. Volume maintenance of onlay grafts in the craniofacial skeleton: microarchitecture versus
embryologic origin. Plast Reconstr Surg 1998;102:291
AUTOGRAFTS
3. What is a relative advantage of using cartilage as an autograft compared to free autologous bone graft?
C. Resorption is rare.
Compared to autologous free bone graft, cartilage graft has significantly lower rate of resorption.
Chondrocytes are capable of surviving within normal matrix without fibrous ingrowth or resorption
2,3,4,5,6
risk,
warp
which allows for great fidelity of graft take and permanence. However, cartilage does tend to
3,7,8
and can be difficult to mold given its flexibility compared to bone graft.
REFERENCES
1. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin Otolaryngol 1998;23:209
2. Lin KY, Bartlett SP, Yaremchuck MJ, et al. The effect of rigid fixation on the survival of onlay bone grafts: an experimental study. Plast Reconstr Surg 1990;86:449
3. Peer LA. Diced cartilage grafts. Arch Otolaryngol 1943;38:156
4. Peer LA. Cartilage grafting. Br J Plast Surg 1954;7:250
1
Chapter 27&Implants and Alloplasts (Nonbreast) 181
5. Ballantyne DL, Rees TD, Seidman I. Silicone fluid: response to massive subcutaneous injections of
dimethylpolysiloxane fluid in animals. Plast Reconstr Surg 1965;36:330
6. Werther JR. Not seeing eye to eye about septal grafts for orbital fractures. J Oral Maxillofac Surg 1998;56:906
7. Antonyshyn O, Gruss JS, Galbraith DJ, et al. Complex orbital fractures: a critical analysis of immediate bone graft
reconstruction. Ann Plast Surg 1989;22:220
8. Waite PD, Clantons JT. Orbital floor reconstruction with lyophilized dura. J Oral Maxillofac Surg 1988;46:727
AUTOGRAFTS
4. What is the most worrisome potential complication of allogeneic graft material placement?
E. Infectious disease transmission.
Although the other options are certainly potential complications of allogeneic graft material placement,
the most worrisome is that of infectious disease (i.e., blood-borne pathogens) transmission. Careful
sterilization techniques have evolved over time, but the risk still remains.
1
REFERENCE
1. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin Otolaryngol 1998;23:209
ALLOGENEIC MATERIALS
5. Which of the following is a considerable disadvantage of utilizing bi-layered acellular dermal regenerative
templates (Integra)?
C. Cost.
Although there is certainly a role of the existing products, the Integra bi-layered acellular dermal matrix
comes with a very high financial burden. Also, it has limited application in aesthetic surgery; products such
as autologous acellular dermal matrix may be of more use, as these can be used for fascial replacement, soft
tissue volume increase, and breast implant encapsulation.
1,2,3
REFERENCES
1. Liu DZ, Mathes DW, Neligan PC, et al. Comparison of outcomes using AlloDerm versus FlexHD for implant-based
breast reconstruction. Ann Plast Surg 2014;72:503
2. Ho G, Nguyen DJ, Shahabi A, et al. A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg 2012;68:346
3. Yeong EK, Chen SH, Tang YB. The treatment of bone exposure in burns by using artificial dermis. Ann Plast Surg
2012;69:607
ALLOGENEIC MATERIALS
6. Which of the following has become the most commonly placed alloplastic material in aesthetic surgery
(nonbreast)?
D. Titanium alloy.
Given its high tolerability, strength, and malleability, titanium alloy alloplasts have become the most commonly used material in aesthetic surgery (nonbreast).
1
REFERENCE
1. Haug RH, Kimberly D, Bradick JP. A comparison of microscrew and suture fixation of porous high density polyethylene orbital floor implants. J Oral Maxillofac Surg 1993;51:1217
ALLOGENEIC MATERIALS
7. Which of the following is an important consideration pertaining to high-density porous polyethylene
(Medpor) implants?
E. Must soak in antibiotic solution prior to placement.
Medpor implants are very easily fixated and stabilized through use of screws,
body, and are not radiodense; however, they must be thoroughly soaked in an antibiotic solution prior to
implant placement to avoid infection complications.
1
are not resorbed by the
182 Part VI&Adjuncts to Aesthetic Surgery
REFERENCE
1. Holmes R, Hagler H. Porous hydroxyapatite as a bone graft substitute on cranial reconstruction: a histometric
study. Plast Reconstr Surg 1988;81:662
ALLOGENEIC MATERIALS
8. Particularly with regard to aesthetic surgery, which of the following is a substantial disadvantage of using
hydroxyapatite in the facial skeleton?
C. Very difficult to remove.
In the event that the removal of a hydroxyapatite implant is aesthetically indicated or desired, the removal
process is extremely difficult to the point that its removal can potentially endanger the mental nerve or
infraorbital nerve, cause excessive bleeding, hematoma, seroma, and undesirable scar tissue.
1,2
REFERENCES
1. Ellis E III, Sinn DP. Use of homologous bone in maxillofacial surgery. J Oral Maxillofac Surg 1993;51:1181
2. Holmes R, Hagler H. Porous hydroxyapatite as a bone graft substitute on cranial reconstruction: a histometric
study. Plast Reconstr Surg 1988;81:662
ALLOGENEIC MATERIALS
9. Which of the following is considered a potential advantage of silicone facial implants compared to other allo-
plastic material types?
A. Implant infections easily managed nonsurgically.
One substantial advantage of silicone facial implants in aesthetic surgery is the capability to manage a potential postoperative infection with (often) antibiotics alone, or (sometimes) needle aspiration for fluid drainage from the implant pocket. Other alloplastic materials would not lend as well to nonoperative
management of suspected infection.
1,2,3
REFERENCES
1. Terino EO, Flowers RS. The Art of Alloplastic Facial Contouring. St Louis: Mosby–Year Book; 2000
2. Ridwan-Pramana A, Wolff J, Raziei A, et al. Porous polyethylene implants in facial reconstruction: outcome and
complications. J Craniomaxillofac Surg 2015;43:1330
3. Rubin PJ, Yarem chuck MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive
and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg 1997;100:1336
28. Progressive Tension Sutures
Stelios C. Wilson, Simon Moradian
See Essentials of Aesthetic Surger y, first edition, pp. 344–352
DEFINITION
1. Progressive tension suturing refers to the technique of which of the following?
A. Anchor flaps over multiple points of fixation in an advanced position.
B. Bringing together rectus abdominis muscles to the midline.
C. High lateral tension closure to improve contour.
D. Closure of the abdominoplasty incision in three layers.
E. Closure of the Scarpa's fascia in an abdominoplasty.
DEFINITION
2. Which of the following applies to the use of progressive tension suturing?
A. Extremely costly.
B. Technically difficult.
C. Takes an extra 60 minutes of operating time, on average.
D. Increases hematoma rates.
E. Decreases seroma rates.
INDICATIONS AND CONTRAINDICATIONS
3. In which of the following reconstructions would progressive tension sutures be inappropriate?
A. Abdominoplasty.
B. Facelift.
C. Subcutaneous brow lift.
D. Reconstructive advancement flaps.
E. Skin grafting.
INFORMED CONSENT
4. When discussing progressive tension suturing (PTSs) with your patients, what should you mention?
A. PTSs eliminate the risk of seroma.
B. Dimpling will not occur.
C. Revision rates are no greater than with traditional techniques.
D. Higher rates of venous thromboembolism.
E. They decrease infection rates.
TECHNIQUE
5. Excessive or obvious dimpling once the next suture is tied may result from which of the following in a patient
with a BMI of 35?
A. Too superficial suture placement.
B. Little to no advancement of the flap.
C. Placement of the sutures in the opposing direction of the flap advancement.
D. Placement of sutures by taking bites of Scarpa's fascia during an abdominoplasty.
E. More likely to occur if using a braided suture.
184 Part VI&Adjuncts to Aesthetic Surgery
TECHNIQUE
6. Once a surgeon–assistant coordination is achieved, placement of progressive tension sutures for an abdomino-
plasty should take approximately how many additional minutes?
A. Less than 5 minutes.
B. 15 minutes.
C. 25 minutes.
D. 40 minutes.
E. 60 minutes.
EQUIPMENT AND PREPARATION
7. What is the preferred suturing technique for placement of progressive tension sutures?
A. Suturing in an interrupted fashion only.
B. Suturing in a continuous fashion only.
C. There is no difference in technique used.
D. Primarily using absorbable sutures in a continuous running fashion.
E. Primarily using nonabsorbable sutures in an interrupted fashion.
OUTCOMES
8. What is the approximate percentage of seroma formation with the use of progressive tension sutures in abdo-
minoplasties with no drains versus traditional abdominoplasties with drains?
A. 2%.
B. 5%.
C. 10%.
D. 15%.
E. 22%.
OUTCOMES
9. When counseling a patient on risks/ benefits of the use of progressive tension sutures (PTSs) during an abdo-
minoplasty, which of the following is associated with the use of PTSs?
A. Decreased hematoma rate.
B. Increased hematoma rate.
C. No significant increased risk of hematomas.
D. Decreased chance of infection.
E. Increased risk of superficial wound dehiscence.
OUTCOMES
10. Which of the following is associated with the use of using progressive tension sutures and forgoing drains in
abdominoplasty?
A. Increased hematoma rates.
B. Increased long-term skin dimpling.
C. Increased seroma rates.
D. Low levels of patient satisfaction.
E. High levels of patient satisfaction.
Chapter 28&Progressive Tension Sutures 185
Answers
DEFINITION
1. Progressive tension suturing refers to the technique of which of the following?
A. Anchor flaps over multiple points of fixation in an advanced position.
Progressive tension suturing is intended to securely anchor flaps over multiple points of fixation in an
advanced position. There are several benefits including eliminating dead space and minimizing tension
on the flap closure. Rectus plication brings the rec tus muscles together in the midline. High lateral tension
closure to improve contour is a principle popularized by Lock wood.
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Andrades P, Prado A. Composition of postabdominoplasty seromas. Aesthetic Plast Surg 2007;31:514
3. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg
1995;96:603–615
DEFINITION
2. Which of the following applies to the use of progressive tension suturing?
E. Decreases seroma rates.
Progressive tension suturing helps to reduce or eliminate dead space. This can help eliminate the need for
drains. Also, progressive tension suturing can improve wound healing through limiting motion,
minimizing tension on advancement flaps, and distributing tension over multiple points of fixation.
Although fluid accumulation is generally compartmentalized to smaller-volume areas that are easily
absorbed, thus limiting seroma, there is no advantage related to infection.
1,2,3
1,2
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Andrades P, Prado A. Composition of postabdominoplasty seromas. Aesthetic Plast Surg 2007;31:514
INDICATIONS AND CONTRAINDICATIONS
3. In which of the following reconstructions would progressive tension sutures be inappropriate?
E. Skin grafting.
Progressive tension sutures are based on a simple surgical concept that can be applied to any procedure
involving an advancement flap. Therefore, they have no specific indications or contraindications.
The placement and healing process of skin grafts would not be an appropriate situation to use progression tension sutures.
1,2,3,4,5
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Andrades P, Prado A. Composition of postabdominoplasty seromas. Aesthetic Plast Surg 2007;31:514
3. Pollock H, Pollock T. Management of face lifts with progressive tension sutures. Aesthet Surg J 2003;23:28
4. Pollock H, Pollock T. Subcutaneous brow lift with progressive tension suture fixation and advancement. Aesthet
Surg J 2007;27:388
5. Rios JL, Pollock T, Adams WP. Progressive tension sutures to prevent seroma formation after latissimus dorsi harvest. Plast Reconstr Surg 2003;112:1779
186 Part VI&Adjuncts to Aesthetic Surgery
INFORMED CONSENT
4. When discussing progressive tension suturing (PTSs) with your patients, what should you mention?
C. Revision rates are no greater than with traditional techniques.
Progressive tension sutures (PTSs) have similar revision rates to operations without the use of PTSs. However,
the use of PTSs significantly reduces the risk of seroma but does not eliminate it. Dimpling can occur but is
almost always temporary. In cases where the dermis rather than the superficial fascial system is being
sutured, such as in a subcutaneous facelift flap, temporary dimpling is more common. There is no evidence
to suggest that the use of PTSs decrease infection rates. It is believed that using P TSs allows for early ambulation in an upright position for abdominoplasty patients, improving venous circulation and reducing the risk
of venous thromboembolism.
1,2,3
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdominoplasty: analysis of 516 consecutive cases.
Aesthet Surg J 2010;30:418
3. Pollock H, Pollock T. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet
Surg J 2012;32:729
TECHNIQUE
5. Excessive or obvious dimpling once the next suture is tied may result from which of the following in a patient
with a BMI of 35?
A. Too superficial suture placement.
When placing progressive tension sutures (PTSs), it is not uncommon to have dimpling that is temporary in
your last suture. Once the next suture is placed, the dimpling should resolve. Excessive or obvious dimpling
can occur with bites that are too superficial, on placing excessiveadvancement of the flap, and on placing the
sutures in the opposing direction. Of note, you can use a slight dimpling to your advantage. There is no evidence to suggest that using a braided suture will result in more or less dimpling. For instance, midline PTSs
during abdominoplasty with slight dimpling can mimic a natural aesthetic contour.
1,2
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Pollock H, Pollock T. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet
Surg J 2012;32:729
TECHNIQUE
6. Once a surgeon–assistant coordination is achieved, placement of progressive tension sutures for an abdomino-
plasty should take approximately how many additional minutes?
C. 25 minutes.
For trained surgeons, no special skills are required to perform this technique and the learning curve is short.
Once a surgeon–assistant coordination is achieved, placement of the sutures takes 20 to 30 minutes, including the in-continuity inset of the umbilicus. In a meta-analysis per formed by Jabbour and colleagues, the
mean difference in surgical time was 23 minutes.
1
REFERENCE
1. Jabbour S, Awaida C, Mhawej R, et al. Does the addition of progressive tension sutures to drains reduce seroma
incidence after abdominoplasty? A systematic review and meta-analysis. Aesthet Surg J 2017;37:440–447
EQUIPMENT AND PREPARATION
7. What is the preferred suturing technique for placement of progressive tension sutures?
C. There is no difference in technique used.
When placing progressive tension sutures (PTSs), the surgeon can use either an interrupted or a continuous
suture. For both techniques, absorbable sutures are generally employed. The use of both smooth and barbed
Chapter 28&Progressive Tension Sutures 187
sutures has been described. Smooth sutures are thought to be equally as effective and less expensive
(Fig. 28.1, Fig. 28.2).
1,2,3,4
Fig. 28.1 Progressive tension sutures.(Source: Reprinted with permission from Pollock H, Pollock T. Progressive tension
sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg 105:2583; discussion 2587,
2000.)
Inset
umbilicus
Fig. 28.2 Continuous sutures. (Source: Technique for Progressive Tension Sutures. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Pollock H, Pollock T. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet
Surg J 2012;32:729
3. Gutowski KA, Warner JP. Incorporating barbed sutures in abdominoplasty. Aesthet Surg J 2013;33(3 Suppl):S76
4. Warner JP, Gutowski KA. Abdominoplasty with progressive tension closure using a barbed suture technique.
Aesthet Surg J 2009;29:221