An Easy and Effective Technique for Silicone Facial Implant Insertion

applied sciences

Article An Easy and Eﬀective Technique for Silicone Facial Implant Insertion and Fixation to Periosteum

Raﬀaele Rauso 1 , Giorgio Lo Giudice 2,*, Carmelo Lo Faro 2 , Giovanni Francesco Nicoletti 3, Romolo Fragola 1, Enrico Sesenna 4 and Gianpaolo Tartaro 1 1 Oral and Maxillofacial Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialities, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; raﬀ[email protected] (R.R.); [email protected] (R.F.); [email protected] (G.T.) 2 Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80138 Naples, Italy; [email protected] 3 Plastic Surgery Unit, Multidisciplinary Department of Medical and Dental Specialties, AOU University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; [email protected] 4 Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, 43126 Parma, Italy; [email protected] * Correspondence: [email protected]; Tel.: +39-34-7250-7395

Received: 28 July 2020; Accepted: 15 September 2020; Published: 18 September 2020

Featured Application: Stable silicone implant insertion and ﬁxation using absorbable yarns potentially used for aesthetic purposes and anatomic reconstructions.

Abstract: In this paper, we present a simple way to place the implant into a harvested pocket and to subsequently fix it percutaneously. Eighteen patients (1 male, 13 females, 4 transgender), underwent facial implant placement; a total of 31 implants were placed (1 pair of angles of the mandible implants, 12 pairs of malar/sub-malar implants, and 5 chin implants). The intraoral approach was performed on 15 patients, and on the remaining three patients, the sub-ciliary lower lid approach was preferred. Patients were followed up for at least one year with a maximum follow-up of seven years (mean 1.8 years). In all the cases, except one, patients healed without complications. One case of implant displacement and infection was recorded. No other complication was documented. The technique described is similar to the one suggested by Peled, although some useful tips were added, namely the use of sutures, not only to fix the implant but also to drive it into the harvested pocket. In addition, larger absorbable “left in place” sutures were used, avoiding accidental implant dislocation during their removal. Further studies are required to gain a more complete understanding of the effectiveness and reproducibility of this surgical technique.

Keywords: facial implant; anchoring suture; smooth facial implant; silicone implant

1. Introduction Due to their eﬃciency and ease of handling, the use of implantable alloplastic biomaterials has become an integral part of facial reconstructive and aesthetic surgery. These materials are suited to be used both in pathological conditions (oncological, post-traumatic, or congenital) and cosmetics. Despite the use of autogenous tissues is considered the gold standard, several disadvantages such as long operative and aftercare times, donor site morbidity, and modeling limitations should be taken into account. The ideal facial implant should be capable of being easily placed and permanently maintain its form and position. The preferable implant material can often vary according to the anatomical site and the surgeon’s preference [1]. The ideal implant material should be cost-eﬀective, safe, non-antigenic,

Appl. Sci. 2020, 10, 6508; doi:10.3390/app10186508 www.mdpi.com/journal/applsci Appl. Sci. 2020, 10, 6508 2 of 9 non-carcinogenic, and resistant to infection. Despite the fact that it should be inert, it should also be easily shaped. Implant materials that allow tissue ingrowth are difficult to shift; however, they are more challenging to remove once they have integrated into the underlying tissue. Two of the most popular implant materials used nowadays are High-Density Porous Polyethylene (Medpor) and Silicone. Silicone rubber is a non-porous material characterized by no fibrovascular ingrowth. The advantages of using silicone, as pointed out by Terino, include excellent biocompatibility, modifiability, conformability, and exchangeability [2]. Although it is true that face implants stability is provided by their sub-periosteal placement and the rigid bone surface of the deep plane, one of the challenges of silicone facial implant surgery is the fixation of the implant itself. The ideal technique should be fast, easy to perform, with a reproducible result among patients and able to minimize possible adverse effects, such as malpositioning or dislocation of the implant itself. Implant migration seems to be correlated with lack of fibrous ingrowth, hematomas, seromas, and infections. While many studies found in the literature report the migration of such prosthetics, most of them focus their attention on the causes, not suggesting any countermeasures [3–5]. Different methods of fixation can influence such an occurrence [6]. Few techniques have been described in the literature in order to provide correct implant placement and avoid its movement until its integration. Peled [7] in 1987 used a screw through the silicone implant to fix it on the underlying bone. von Szalay [8] in 1994 suggested a 24-h percutaneous fixation using 18-gauge needles inserted in soft tissue and deeply into the implant. Peled [9] commented on the work of von Szalay, describing a new technique with the use of percutaneous fixation through nylon sutures removed after 3 to 7 days. There has not been any update of the matter of subject since. In this paper, we present an easy way to place the implant into the harvested pocket and at the same time, fix it percutaneously.

2. Materials and Methods The study was approved by the internal ethical committee of the University (AOU-SUN 167/2011); the patients gave consent for the publication of this paper. From January 2012 to January 2017, 18 patients (1 male, 13 females, 4 transgender), with ages ranging from 24 to 52 years old (mean age 37.6 years old), underwent facial implants placement; a total of 31 implants were placed (1 pair of angles of the mandible implants, 12 pairs of malar/sub-malar implants, and 5 chin implants). In all the cases, smooth silicone implants were used (Implantech, Ventura, CA, USA). Previous facial Polymetylmetacrylate (PMMA) injections were reported by the patient and detected by ultrasonographic examination in one case only. All the patients were light-to-moderate smokers (6 to 15 cigarettes per day). In every case, multiple surgical procedures were performed, and in order to reduce contamination, the facial implants were always inserted ﬁrst, with the exception of when they were associated with breast implants (Table1).

Table 1. All surgeries associated with facial implant insertions are listed.

Type of Implant Inserted Surgeries Associated Facelift Breast augmentation Malar implants Upper and lower blepharoplasty Canthopexy CO2 forehead treatment Upper blepharoplasty Malar implants Neck liposuction Chin reduction Malar implants Rhinoplasty Malar implants Chin reduction Malar implants Upper lip lift Malar implants Lip augmentation Malar implants Lip augmentation Appl. Sci. 2020, 10, 6508 3 of 9

Table 1. Cont.

Type of Implant Inserted Surgeries Associated Malar implants Breast augmentation Malar implants Breast augmentation Malar implants Upper blepharoplasty Forehead lift Sub-malar implants Brow lift CO2 forehead treatment Mid-facelift Sub-malar implants Augmentation Mastopexy Sub-malar implants Upper blepharoplasty Nasal tip surgery Chin implant Neck liposuction Chin implant Neck liposuction Chin implant Rhinoplasty Chin implant Rhinoplasty Chin implant Neck liposuction Secondary rhinoplasty Superior and inferior lip implants Canthopexy Jaw angle lengthening implants Orbital rim remodeling Otoplasty Full facial CO2 treatment

The intraoral approach was performed in 15 cases, and in the other 3 cases, the sub-ciliary lower lid approach was preferred. Implants were inserted with the method described in the “surgical technique” section and were ﬁxed percutaneously. Patients were followed up at least for 1 year, with a maximum follow-up of 7 years (mean 1.8 years).

Surgical Technique The procedure starts with the infiltration of two percent lidocaine (Lignospan) local anesthetic with a vasoconstrictor (1:100,000). An intraoral incision is performed with a scalpel, and a myomucosal flap is elevated. Before proceeding with a deeper dissection, any bleeding vessel is cauterized. Afterwards, the dissection goes on, and a subperiosteal pocket is created using periosteal elevators. After the pocket is harvested, the implant sizer is inserted into the pocket to ensure a correct dissection. Once the size of the final implant to be inserted is thoroughly considered and checked, the implant is meticulously placed directly over the skin in the area where it is planned to be located ready for the marking phase (chin, mandibular angle, malar area, etc.) (Figure1). Appl. Sci. 2020, 10, x FOR PEER REVIEW 4 of 9

FigureFigure 1. Once 1. Once the the implant implant pocket pocket is harvested,harvested, the the selected selected implant implant is located is located over the over skin, the above skin, the above the pocket.pocket. TwoTwo paramedian paramedian points points over over the implant, the implant, about 1about cm from 1 cm each from other, each are identifiedother, are and identified marked, and marked,passing passing a 2/0 straight a 2/0 straight needle up needle to the underliningup to the un skinderlining in order toskin mark in bothorder the to implant mark andboth the the skin. implant and the skin.

Two paramedian points over the implant are identified and pierced circa 1 cm from each other, using a 2/0 straight needle that runs to the underlining skin; then fixation points are marked on the implant and over the skin. The implant is soaked in a povidone-iodine solution (BETADINE soluzione cutanea, GMM FASRMA srl, Segrate-Milano-Italy) at 50% diluted saline solution. A 2/0 straight needle absorbable suture (VICRYL 2/0 straight needle, Ethicon INC 2007) passes from outside to inside, from the skin to the subperiosteal pocket, and then through the implant from the outer to the inner side following the first marked points. Then the needle runs through the implant again in a reverse direction, from the inner to the outer side, from the pocket to the skin through the soft tissues, following the second marked points on the implant and above the skin. During these steps, the implant is still outside the pocket. The two suture ends are then pulled by the assistant surgeon, and the first surgeon carefully places the implant into the previously harvested pocket (Figure 2).

Figure 2. Once the suture has passed through the soft tissue and the implant, the two sutures ends are pulled by the assistant surgeon, and the first surgeon carefully places the implant into the previously harvested pocket.

The suture is tied over a piece of foam to avoid direct knot contact above the skin, firmly securing the outer surface of the implant to the periosteum. As soon as the pocket is closed, the inner side will be in direct contact with the bone surface. Intraoral accesses are closed in a double layer with absorbable sutures (VICRYL 3/0, Ethicon INC 2007). The suture stays in place, anchoring the implant to the harvested pocket and in the pre-operatively planned area, and is cut at the emerging points Appl. Sci. 2020, 10, x FOR PEER REVIEW 4 of 9

Figure 1. Once the implant pocket is harvested, the selected implant is located over the skin, above the pocket. Two paramedian points over the implant, about 1 cm from each other, are identified and marked, passing a 2/0 straight needle up to the underlining skin in order to mark both the implant and the skin.

Two paramedian points over the implant are identified and pierced circa 1 cm from each other, Appl. Sci. 2020, 10, 6508 4 of 9 using a 2/0 straight needle that runs to the underlining skin; then fixation points are marked on the implant and over the skin. The implant is soaked in a povidone-iodine solution (BETADINE Two paramedian points over the implant are identified and pierced circa 1 cm from each other, soluzione cutanea, GMM FASRMA srl, Segrate-Milano-Italy) at 50% diluted saline solution. using a 2/0 straight needle that runs to the underlining skin; then fixation points are marked on the A 2/0implant straight and overneedle the skin.absorbable The implant suture is soaked (VICRYL in a povidone-iodine 2/0 straight solutionneedle, (BETADINE Ethicon INC soluzione 2007) passes from outsidecutanea, to GMMinside, FASRMA from the srl, skin Segrate-Milano-Italy) to the subperiosteal at 50% dilutedpocket, saline and solution. then through the implant from the outer to theA 2 inner/0 straight side needle following absorbable the first suture marked (VICRYL points. 2/0 straight Then needle, the needle Ethicon runs INC through 2007) passes the implant again in froma reverse outside direction, to inside, fromfrom the the skin inner to the to subperiosteal the outer side, pocket, from and the then pocket through to the the implant skin fromthrough the the outer to the inner side following the first marked points. Then the needle runs through the implant soft tissues, following the second marked points on the implant and above the skin. During these again in a reverse direction, from the inner to the outer side, from the pocket to the skin through the steps, thesoft implant tissues, followingis still outside the second the marked pocket. points The on thetwo implant suture and ends above are the then skin. Duringpulled these by steps,the assistant surgeon,the and implant the first is still surgeon outside the ca pocket.refully The places two suture the implant ends are theninto pulled the previously by the assistant harvested surgeon, pocket (Figure 2).and the first surgeon carefully places the implant into the previously harvested pocket (Figure2).

Figure 2.Figure Once 2. theOnce suture the suture has haspassed passed through through thethe soft soft tissue tissue and theand implant, the implant, the two suturesthe two ends sutures are ends are pulledpulled by bythe the assistant assistant surgeon, surgeo andn, and the ﬁrst the surgeon first carefullysurgeon places carefully the implant places into the the previouslyimplant into the previouslyharvested harvested pocket. pocket. The suture is tied over a piece of foam to avoid direct knot contact above the skin, firmly securing Thethe suture outer is surface tied over of the a implant piece toof the foam periosteum. to avoid As direct soon as knot the pocket contact is closed, above the the inner skin, side firmly will be securing the outerin surface direct contact of the with implant the bone to surface.the periosteum. Intraoral accesses As soon are closedas the in pocket a double is layerclosed, with the absorbable inner side will be in directsutures contact (VICRYL with 3/0, Ethicon the bone INC 2007). surface. The suture Intraoral stays in accesses place, anchoring are closed the implant in toa thedouble harvested layer with pocket and in the pre-operatively planned area, and is cut at the emerging points over the skin after 4 days, absorbable sutures (VICRYL 3/0, Ethicon INC 2007). The suture stays in place, anchoring the implant leaving the suture inside, thus avoiding accidental implant dislocations (Figures3 and4). to the harvested pocket and in the pre-operatively planned area, and is cut at the emerging points Appl. Sci. 2020, 10, x FOR PEER REVIEW 5 of 9

Appl. Sci. 2020, 10, x FOR PEER REVIEW 5 of 9 over Appl.the Sci.skin2020 after, 10, 6508 4 days, leaving the suture inside, thus avoiding accidental implant dislocations5 of 9 (Figuresover 3the and skin 4). after 4 days, leaving the suture inside, thus avoiding accidental implant dislocations (Figures 3 and 4).

Figure 3. The present picture shows the inserted malar implant, with the percutaneous suture FigureanchoringFigure 3. The 3. The the present presentimplant picture to the harvested shows shows the the insertedpocket, inserted co malarrresponding implant,malar implant, to with the the pre-operatively percutaneouswith the percutaneous sutureplanned anchoring area. suture anchoringthe implant the implant to the harvested to the harvested pocket, corresponding pocket, corresponding to the pre-operatively to the pre-operatively planned area. planned area.

Figure 4. Schematic ﬁgure of the technique using a malar implant. The implant (A) is held externally Figurewith Klemmer 4. Schematic forceps figure (B). of While the technique the periosteal using pocket a malar is implant. kept open The by implant two retractors (A) is held (C), externally the suture with(red line)Klemmer is passed forceps through (B). While the planned the periosteal points, pocket from the is kept skin open to the by pocket two re throughtractors the (C), implant the suture and (redreverse, line) as is shownpassed bythrough the blue the arrows. planned points, from the skin to the pocket through the implant and reverse, as shown by the blue arrows. 3.Figure Results 4. Schematic figure of the technique using a malar implant. The implant (A) is held externally with Klemmer forceps (B). While the periosteal pocket is kept open by two retractors (C), the suture 3. Results (red Inline) all is of passed the cases, through bar one, the patientsplanned healedpoints, withoutfrom the complications skin to the pocket (Figures through5–7). the implant and reverse,In all as of shown the cases, by the bar blue one, arrows. patients healed without complications (Figures 5–7).

3. Results In all of the cases, bar one, patients healed without complications (Figures 5–7). Appl. Sci. 2020, 10, 6508 6 of 9

Appl. Sci. 2020,, 10,, xx FORFOR PEERPEER REVIEWREVIEW 6 of 9 Appl. Sci. 2020, 10, x FOR PEER REVIEW 6 of 9

Figure 5. 5. Pre-operativePre-operative (A (),A), immediate),immediate immediate postoperativepostoperative postoperative ((B),), ( Bandand), and two-yeartwo-year two-year follow-upfollow-up follow-up ((C)) resultsresults (C) results ofof aa 52-52- of Figure 5. Pre-operative (A), immediate postoperative (B), and two-year follow-up (C) results of a 52- year-olda 52-year-old transgender transgender patient patient having having malar malar implan implantststs insertion.insertion. insertion. DuringDuring During thethe samesame the sameoperatingoperating operating time,time, year-old transgender patient having malar implants insertion. During the same operating time, facelift,time,facelift, facelift, breastbreast breast augmentation,augmentation, augmentation, upperupper upper andand and lowerlower lower blepharoplasty, blepharoplasty, canthopexy, canthopexy, and and CO2 CO2 forehead facelift, breast augmentation, upper and lower blepharoplasty, canthopexy, and CO2 forehead treatmentstreatments werewerewere alsoalsoalso performed. performed.performed. In InIn (B) (B)(B) blue blueblue arrows arrowsarrows point pointpoint to toto the thethe anchoring anchoringanchoring suture suturesuture used usedused to to insertto insertinsert and andand ﬁx treatments were also performed. In (B) blue arrows point to the anchoring suture used to insert and fixthefix thethe implants. implants.implants. fix the implants.

Figure 6. Pre-operative (A),), intraoperativeintraoperative viewview ofof thethe implantimplant placementplacement ((B),), andand one-yearone-year follow-follow- Figure 6. Pre-operative ((AA),), intraoperativeintraoperative viewview of of the the implant implant placement placement (B (),B), and and one-year one-year follow-up follow- up (C)) resultsresults ofof aa 42-year-old42-year-old transgendertransgender patientpatient hahaving a Jaw angle lengthening implant insertion. up(C) ( resultsC) results of of a 42-year-olda 42-year-old transgender transgender patient patient having having a a Jaw Jaw angleangle lengtheninglengthening implant insertion. insertion. During the same operating time, secondary rhinoplasty, superior and inferior lip implants, During thethe same same operating operating time, time, secondary secondary rhinoplasty, rhinoplasty, superior superior and inferior and lipinferior implants, lip canthopexy, implants, canthopexy, orbital rim remodeling, otoplasty, and fullll facialfacial CO2CO2 treatmenttreatment werewere alsoalso performed.performed. InIn canthopexy,orbital rim remodeling, orbital rim remodeling, otoplasty, and otoplasty, full facial and CO2 full treatment facial CO2 were treatment also performed. were also performed. In (B) the red In ((B)) thethe redred arrowarrow pointspoints toto thethe anchoringanchoring sutusuturere usedused toto insertinsert andand fixfix thethe implant.implant. (arrowB) the pointsred arrow to the points anchoring to the sutureanchoring used sutu to insertre used and to ﬁxinsert the implant.and fix the implant.

Figure 7. Pre-operative (A),), andand three-yearthree-year follow-upfollow-up ((B)) resultresult ofof aa 54-year-old54-year-old patientpatient havinghaving sub-sub- Figure 7. Pre-operative (A), and three-year follow-up (B) result of a 54-year-old patient having sub- malarFigure implant 7. Pre-operative placement. (DuringA), and the three-year same operating follow-up time,time, (B foreheadforehead) result of lift,lift, a browbrow 54-year-old lift,lift, andand patient CO2CO2 foreheadforehead having malar implant placement. During the same operating time, forehead lift, brow lift, and CO2 forehead treatmentsub-malartreatment werewere implant alsoalso placement. performed.performed. During the same operating time, forehead lift, brow lift, and CO2 treatmentforehead treatment were also wereperformed. also performed. One case of implant displacement and infection was recorded on the only patient who had One case of implant displacement and infection was recorded on the only patient who had undergone previous facial polymetylmetacrylate (PMMA)(PMMA) injections.injections. ThreeThree weeksweeks afterafter surgery,surgery, undergone previous facial polymetylmetacrylate (PMMA) injections. Three Three weeks weeks after after surgery, surgery, superior displacement of the left sub-malar implant with marked oedema and inflammation was superior displacement of of the left sub-malar im implantplant with marked oedema and inflammation inﬂammation was detected (Figure 8). detected (Figure 88).). Appl. Sci. 2020, 10, 6508 7 of 9 Appl. Sci. 2020, 10, x FOR PEER REVIEW 7 of 9

Figure 8. UpperUpper displacement displacement of of the sub-malar implant.

Implants werewere removed removed bilaterally; bilaterally; during during surgical surgical removal removal an abscess an abscess in the pocketin the waspocket detected was detectedand subsequently and subsequently drained. drained. No other complication was recorded. Postoperative surgical surgical swelling lasted between two and three weeks for all the the patients. patients. Once Once discharged, discharged, the the patients patients were were told told to to avoid avoid large large facial facial muscular muscular movements for seven days. They They were were also also prescribed prescribed oral oral antibiotic antibiotic and and painkillers painkillers for for five ﬁve days, days, the use of 0.2% chlorhexidine digluconate digluconate mouthwas mouthwashh twice twice a a day, day, and instructed to apply a cream containing hyaluronate and amino acids (Aminogam; Professional Dietetics, Milan, Milan, Italy) Italy) over the intraoralintraoral wound for 14 days. days. In In cases cases of of sub-ciliary sub-ciliary lower lower lid lid approaches, approaches, steri-strips steri-strips were were placed placed over over the surgical site.

4. Discussion Discussion In a recent review performed by Rojas et al., it was concluded that facial augmentation with alloplastic material is a well-established techniqu techniquee with with a low incidence of complications for both Silicone and Medpor malar, chin, and mandibularmandibular implantsimplants [[5].5]. The The insertion technique technique of of these implantsimplants is the same, regardless of the used materials.materials. Although Although the the fixation fixation of silicone implants can be performed with several techniques, Medpor is exclusively fixedfixed with screws. Similarly, silicone implants can benefit benefit from screw fixation,fixation, although the rigid fixation fixation could damage the smooth silicone implant. Consequently, the use of anchoring sutures to the periosteum or th thee percutaneous fixation fixation of the implantimplant has been described in the literature [[10,11].10,11]. Szalay, inin 1992,1992, first first described described a faciala facial implant implan fixationt fixation technique, technique, which which he carried he carried out by placingout by placingtwo percutaneous two percutaneous 18-gauge 18-gauge needles needles through through the soft the tissue, soft tissue, deeply deeply into the into implant, the implant, which which then thenremained remained in place in place for 24–48 for 24–48 h [8]. h [8]. In 1994, Peled replied to Szalay, suggesting a similar technique for temporary fixation fixation of the silicone prosthesis [9]. [9]. The The implan implantt was was placed placed onto onto the the skin skin in in the the desired desired location; location; two two symmetrical symmetrical points were marked on the silicone (A’-B’) and th thee corresponding point on the skin (A-B) that would then overlie the implant. A A 4–0 4–0 nylon nylon suture suture was was passed through the full thickness of the soft tissue and from the pocket through the implant (anteropos (anteroposterior)terior) at point A and made its way out through the silicone (posteroanterior) at point B’. It then ra rann through the soft tissue and the skin at cutaneous point B. The suture was taped onto the skin or tied over a piece of foam and remained in place for three to seven days [9]. [9]. In this this paper, paper, the used fixation fixation technique was was si similarmilar to the one one reported reported by by Peled Peled 26 26 years years ago, ago, although somesome usefuluseful variations variations were were added. added. We We found found that that inserting inserting the needlethe needle into theinto implant the implant while whileit was it outside was outside rather rather than inside than inside the pocket the pocket to be of to considerable be of considerable help; once help; the once needle the wasneedle passed was passedthrough through the four the points four (two points through (two the through soft tissues the soft and tissues two through and two the through implant), the whilst implant), accompanied whilst accompaniedby the lead surgeon, by the lead the assistantsurgeon, surgeonthe assistant pulls su thergeon two pulls sutures the thustwo sutures carefully thus placing carefully the implantplacing theinto implant the pocket. into the Finally, pocket. the Finally, suture the will suture be tied will over be tied the over skin. the This skin. variation This variation allows allows having having better better control on the final position of the implant contrary to the “blind” fixation proposed by Peled, with an overall stricter relationship of the implant to the periosteum and the underlining bone. Appl. Sci. 2020, 10, 6508 8 of 9 control on the final position of the implant contrary to the “blind” fixation proposed by Peled, with an overall stricter relationship of the implant to the periosteum and the underlining bone. Moreover, anchoring the suture outside the pocket allows the pre-operative position planning to be respected, avoiding unwanted malpositioning during fixation maneuvers. The firm position of the implant provided by the suture fills any gaps between the implant and both the superficial and the deep plane where hematoma or seroma could accumulate, causing its dislocation. Some authors suggested that the use of porous implants could decrease the incidence of this complication although the occurrence rate is generally low and not statistically divergent between porous and non-porous materials (0.75–0.83%) [4]. Instructing the patients to avoid wide facial muscular movements for at least seven days is mandatory since the influence of muscular forces could promote the processes involved in this complication. Another difference with Peled’s technique is the use of absorbable sutures that are left in place, with just the suture emerging from the skin being cut after four days. This is done in order to avoid implant displacement during suture removal. Polyglactin suture has great knot security, is biologically well-tolerated, and loses its tensile strength after about 14 days [12,13]. Therefore, during the first four postoperative days, the fixation of the implant is guaranteed while after the cut of the external threads, the inner parts will still hold some tension through the subcutaneous and periosteal healing tissue, until its full degradation. If left in place, the nylon thread suggested by Peled would more likely cause chronic inflammation compared to Vicryl and is therefore removed altogether. The action of removing the thread itself could cause unpredictable implant displacement or rupture, depending on the sliding through the scar tissue and on the capsule formation around the implant. Dimpling, notching, or inflammatory sequelae with the use of a braided suture such as Vicryl were not detected. Silicone implants induce a mild inflammatory response, followed by the formation of a thin dense fibrous capsule that surrounds the implant itself, ensuring a high degree of stability. Even though the inflammatory response could exceed, causing capsular contracture and has been thoroughly reported for soft tissue implants (mostly breast implants), there is little to no report in the literature of capsular contracture in facial implants [14]. Our experience conforms to the literature. In our series, 31 implants were inserted, and 1 case of infection/displacement was recorded; however, this complication occurred three weeks after surgery, and it developed exclusively in a patient who had had a non-absorbable filler injected into the face. Permanent fillers are a relative contraindication to facial implants, as these medical devices have to be placed below the periosteum and the fillers that are used are injected into the soft tissue, so we have two different planes. The complication that developed could have been associated to the suboptimal pocket harvesting with subsequent contamination of the permeant filler that had been previously injected. The limitation of this study is represented by the low number of patients treated.

5. Conclusions Anchoring a smooth implant for the initial postoperative days can avoid malpositioning. More than 25 years ago, the first technique to percutaneously fix facial implants was described. The technique described in this case series is similar to the one suggested by Peled, although some variations have been added. Such additions are represented by the use of sutures, not only to fix the implant but also to place it into the harvested pocket. Another useful tip is represented by the use of a larger absorbable suture that is “left in place”, cutting only the suture emerging above the skin, thus avoiding accidental implant dislocation or lesions during suture removal. Despite this short case series showing some advantages of the aforementioned techniques to the authors in question, further analysis by means of case-control studies are required to gain a more complete understanding of the effectiveness and reproducibility of this surgical technique.

Author Contributions: Conceptualization, R.R.; methodology, G.F.N.; formal analysis, C.L.F.; data curation, R.F.; writing—original draft preparation, R.R.; writing—review and editing, G.L.G.; supervision, E.S.; project administration, G.T. All authors have read and agreed to the published version of the manuscript. Appl. Sci. 2020, 10, 6508 9 of 9

Funding: This research received no external funding. Conﬂicts of Interest: The authors declare no conﬂict of interest.

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