Conclusion

MERSILENE IMPLANTS

Mersilene (Ethicon, Somerville, NJ) is a polyethyleneteretha-late, which is a meshed polymer. It facilitates fibrous tissue ingrowth, making it more difficult to remove. This material can be used as a draping graft over the dorsum or the nasal tip area, or it can be rolled for utilization for dorsal augmentation. The following technical aspects should be considered when using rolled mesh. First, it has tapered ends. Second, the implanted alloplast must be placed away from the incision, to minimize exposure. Third, medial osteotomies can increase fibrosis and help position the rolled mesh. Finally, caution

The use of autogenous cartilage material, preferably from the nasal septum, continues to be the graft of choice for nasal reconstruction. However, technical advances in the development of alloplastic implants such as e-PTFE provide an enticing alternative when autogenous cartilage is limited.

Graft and implant materials are very controversial. Their discussion always engenders strong opinions from those who favor one material over another. Figure 32-1 summarizes the author's preferences for selection of implant material. A wide variety of materials can be used successfully in nasal reconstruction when sound surgical principles are employed in conjunction with good surgical technique.

GRAFT/IMPLANT SELECTION

SUPPORT

Nasal Tip

1. Autogenous septal cartilage

2. Autogenous auricular cartilage

3. Irradiated costal cartilage

4. Alloplastic implant

Nasal Dorsum

1. Calvarium bone graft

2. Autogenous rib graft with K-wire

1. Autogenous septal cartilage

2. Autogenous auricular cartilage

3. Alloplastic implant (e-PTFE)

4. Alloplastic implant

(Mersilene mesh)

AUGMENTATION

Nasal

Tip

Nasal Dorsum — Small Defect

Nasal Dorsum — Small Defect

1. Autogenous septal cartilage

2. Alloplastic implant (e-PTFE)

3. Alloplastic implant

(Mersilene mesh)

Nasal Dorsum — Large Defect

1. Alloplastic implant (e-PTFE)

2. Homograft — irradiated costal cartilage

3. Calvarium bone graft

4. Autogenous rib graft

Figure 32-1 Algorithm for selection of implant material representing author's personal preference.

REFERENCES

Beeson—CHAPTER 32

Stucker FJ. Use of implantation in facial deformities. Laryngoscope 1977;87:1523-1527

Adams JS. Grafts and implants in nasal and chin augmentation. Otolaryngol Clin North Am 1987;20:913-930 Silver WE, Goldberg J. Nasal grafts and implants. Facial Plast Surg Clin North Am 1994;2:477-499

Tardy ME, Denneny J, Fritsch MH. The cartilage autograft in reconstruction of the nose and face. Laryngoscope 1985;95: 523-533

Brent B. The versatile cartilage autograft; current trends in clinical transplantation. Clin Plast Surg 1979;6:163-180 Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its causes and prevention. Br J Plast Surg 1958; 10:257

Donald PJ. Cartilage grafting in facial reconstruction with special consideration of irradiated grafts. Laryngoscope 1986;96: 786-807

Sessions DG, Stallings JO. Correction of saddle nose deformity. Laryngoscope 1972;82:2000-2007 Gunter JP, Rohrich RJ. Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage. Plast Reconstr Surg 1990;86:39-45

Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping. Plast Reconstr Surg 1997;100;161-169

11. Hardesty RA, Marsh JL. Cranial facial on-lay bone grafting. Plast Reconstr Surg 1990;83:3

12. Powell NB, Riley RW. Facial contouring with outer table calvarium bone. Arch Otolaryngol Head Neck Surg 1980;115: 1454-1456

13. Peer LA. The fate of autogenous human bone grafts. Br J Plast Surg 1950;3:233-243

14. Brandon GE, Kern EB, Neel BN. Autografts of uncrushed and crushed bone and cartilage. Arch Otolaryngol Head Neck Surg 1979;105:75-80

15. Schuller DE, Bardach J, Krause CJ. Irradiated homologous costal cartilage for facial contour restoration. Arch Otolaryngol Head Neck Surg 1977;103:12-15

16. Lefkovits G. Irradiated homologous costal cartilage for augmentation rhinoplasty. Ann Plast Surg 1990;25:317-327

17. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg 1997;13:279-290

18. Wainwright D, Madden M, Luterman A, et al. Clinical evaluation of an acellular allograft dermal matrix in full-thickness burns. J Burn Care Rehabil 1996;17:124-136

19. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg 1998;13:279-290

20. Sclafani AP, Thomas JR, Cox AJ, et al. Clinical and histologic response of subcutaneous expanded polytetrafluoroethylene (Gore-Tex) in porous high-density polyethylene (Medpor) implants to acute and early infection. Arch Otolaryngol Head Neck Surg 1997;123:238-336

21. Silver FH, Maas CS. Biology of synthetic facial implant materials. Facial Plast Surg Clin North Am 1994;2:241-255

22. Davis PK, Jones SM. The complications of silicone implants. Br J Plast Surg 1971;24:405-411

23. Gilmore J. Use of Vicryl mesh in prevention of postrhinoplasty dorsal irregularities. Ann Plast Surg 1989;22:105-107.

24. Maas CS, Gnapp DR, Bumpous J. Expanded polytetrafluoroethylene [Gore-Tex] soft tissue patch (in facial augmentation). Arch Otolaryngol Head Neck Surg 1993;119:1006-1014

25. Godin MS, Waldman SR, Johnson CM. The use of expanded polytetrafluoroethylene [Gore-Tex] in rhinoplasty. Arch Otolaryngol Head Neck Surg 1993;121:1131-1136

As a conservative surgeon, I believe in creating natural-appearing, well-supported, well-balanced noses. As a result, I not infrequently find the need to add something to create projection, balance, or support. Like everyone else, I try to use autologous septal cartilage wherever possible. There have been times, however, when there just wasn't enough septum to do the job. So I have turned, on occasion, to the use of implants. When academics present at meetings, or write about the successful experience they've had with a new implant material, I am likely to give it a try if it seems to be safe, and sensible, and if their numbers are good. Upon reviewing my own experience, I am glad I took their advice less than half the time, so for me this is a time to reassess this question, and I invite the reader to do the same.

My current thesis is that we should scrupulously avoid placing implants in the nose. My rationale follows.

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