My Personal Experience

I do not perform vast numbers of rhinoplasties. It is for this reason that I believe my experience is potentially most valuable to the majority of practitioners who have similar caseloads.

MERSILENE MESH

I have used Mersilene mesh three times in my career:

Patient 1: Placed through a transfixion incision to augment the premaxillary area, the implant became infected within 1 month of surgery and drained whenever the patient was not on antibiotics. The implant was ultimately removed without difficulty.

Patient 2: Rolled to quickly augment a dorsum that I accidentally overreduced using an osteotome, this implant remained in place but eventually swelled a little, giving the patient the notion that she had wasted her money on a rhinoplasty. The implant was removed with minimal difficulty, and the nose reshaped with satisfactory outcome.

Nowb'c

"Clinical trials have shown resorption and loss of material substance ... [and] have made this mostly of historical interest with respect to rhinoplasty."

"Removal of infected implants very difficult... nearly impossible . and reported infection rates between 4 and 9%."

"Because of this disastrous outcome

(in the jaw)... Proplast is no longer approved by the FDA for any implantation uses."

Not even mentioned by either author (probably on advice of their attorneys).

"For more than 35 years ... proved ... to be a stable, reliable, implant material."

aAdams JS. Grafts and implants in nasal and chin augmentation—a rational approach to material selection. Otol Clin North Am 1987;20:913-930. b Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plastt Surg 1997;13:279-290.

cKridel RWH, Kraus WM. Grafts and implants in revision rhinoplasty. Facial Plast Surg Clin North Am 1995;3:473-486.

Patient 3: Placed to correct a slight mid-third unilateral depression, this implant began to exude a foul odor noticed by the patient. Athough clinically there was no infection, one could see the graft fibers protruding through the intercartilaginous incision site. At the first revision, I reopened the incision and removed any graft within 3 mm of the incision. The problem recurred after many months, and I had to return to remove the remainder. The excisions were technically difficult in both instances. The final result was acceptable.

SILASTIC

I knew that Silastic could be problematic in the tip and the dorsum, but I allowed myself to be convinced that it might be acceptable in the premaxilla. Two such implants were placed. Both lasted about 5 years:

Patient 1: Placed in a secondary rhinoplasty to project a nasal tip complex, the implant accomplished this task beautifully. Over the course of years, however, beginning months after insertion, foul drainage would occur from a small portion of the incision. Antibiotics worked for a time, but infection would always recur. Because the patient loved the appearance, the implant was removed long after I would have wanted to remove it otherwise. The tip remained in good position, and no further surgery was needed.

Patient 2: This patient had not undergone surgery but did have a drug-induced septal perforation, and resultant loss of premaxillary support. Placement was similar to that used in patient 1. This patient did well until 5 years later, when she presented with asymptomatic exposure from the region of the hemitransfixion incision. The implant was removed; no further surgery was needed.

GORE-TEX

Gore-Tex is currently in fashion in our literature. Eight implants have been placed. Three have required removal, with the following results:

Patient 1: A 2-mm piece of reinforced Gore-Tex was placed into the nose ofa man who had injured his nose in Vietnam. He had undergone a rhinoplasty for an acute condition, leaving him with an overreduced dorsum and valve collapse. The implant was placed through endonasal incisions. He did well, with his airway as well as his appearance improved for 1 year. At that time he began to experience episodes of nasal swelling. The implant could be seen protruding from the intercartilaginous region on the left side. The area was explored and the graft was shortened. He was placed on oral, intravenous antibiotics consistent with cultures obtained at the time. After several months without symptoms, the nasal swelling and erythema recurred. The implant was removed. So far, he has not needed any further surgery.

Patient 2: Rolled Gore-Tex was used to augment the pre-maxilla in a primary rhinoplasty. After an initial good result, the material spontaneously became infected, resulting in foul drainage from the transfixion incision. The implant was removed after two temporarily successful courses of antibiotics. The nose has maintained its position.

Patient 3: Reinforced Gore-Tex was used as a spreader in a 55-year-old man who had had previous septoplasty, who had internal valve collapse and needed support in conjunction with his cosmetic/functional rhinoplasty. The grafts functioned nicely for about 12 months, after which a foul odor alerted us to the extrusion of one of the grafts through the septal mucosa. He had a great deal of nasal dorsal and columellar swelling with these infections, and this was his greatest concern. Ultimately, despite antibiotics and graft trimming, the implants required removal. The swelling has resolved, and he has been satisfied with the result.

Although no serious sequelae have resulted from my implant experiences, the trouble resulting does not seem to be worth the time saved or donor site morbidity saved. What about recipient site morbidity?

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