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Fig. 22. Radiograph of patient in Fig. 19 after bone graft reconstruction, placement of rigid bicortical plate, and osseointegrated fixtures. The final bone graft result shows remarkable dense bone in sufficient quantity to support an implant-retained prosthesis. (From Marx RE. Platelet-rich plasma: a source of multiple autologous growth factors for bone grafts. In: Lynch SE, Genco RJ, Marx RE, editors. Tissue engineering: application in maxillofacial surgery and periodontics. Chicago: Quintessence Books; 1999. pp. 71-82; used with permission.)

Fig. 23. Postoperative day 7: right-side incision closed with fast-absorbing catgut sutures. Note the erythema and friable skin edges.

Fig. 24. Postoperative day 7, same patient as in Figs. 16 and 23 having incision line closed with platelet-rich plasma with growth factors and no cutaneous sutures. Note less inflammation, erythema, and swelling, and a more rapid epithelialization when compared with Fig. 23.

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PRP can also be used during transconjunctival l ower eyelid blepharoplasty and to cover skin after laser-resurfacing procedures. Other potential uses of PRP presently under investigation involve replacement of cutaneous sutures in closure of tension-free areas. Cutaneous closure in upper eyelid blepharoplasty, indirect brow lift, and rhytidectomy can be accomplished with multiple coats of PRP (Figs. 15,16). The skin is approximated with subcuticular and subcutaneous sutures, thereby releasing any tension on the cutaneous surface prior to the coating of skin with PRP. On the incision lines, the PRP is applied in 2-3 layers, allowing the glue to dry in between applications. A nonadherent dressing is applied over the platelet gel to avoid removal.

Clinical observations with PRP PRP has been used in a total of 414 cases in combination by both authors. The first effect of the

Fig. 27. Postoperative day 21, same patient having right-side i ncision closed with sutures and showing obvious signs of proliferation on the skin edges; strands evident on surface are a sign of collagen deposition. Incision still indurated with signs of angiogenesis. Banks and should be verified with state medical boards and appropriate health care agencies.

Applications of PRP Many of the benefits of PRP and PPP are applicable to flap and cutaneous surgery. During rhytidectomy, the facial and neck flaps are sprayed with PRP on the undersurface and deep tissue (Fig. 13). The amounts of PRP sprayed under the flaps do not need to be excessive because of the concentrated properties of PRP, and in most cases a light coat of the glue is all that is necessary. On most cases, 15-20 cc of PRP is enough to coat the undersurface of the facial, neck, and brow flaps. At the end of the procedure, a folded 4 x 4 gauze is rolled in the direction of the incision line to milk any excessive fluid (Fig. 14). Massaging the flaps during this maneuver must be avoided to prevent shearing the tissues under the flap that may l ead to bleeding. PPP is used in similar fashion for added hemostasis in the surgical bed and facial flaps.

Fig. 28. Postoperative day 21, same patient having left-side incision closed with PRP, no inflammation or excessive angiogenesis, incision line with better cutaneous quality, no exaggerated stranding, and better appearance than right incision.