Facial Augmentation with Rolled Mesh Material Supramid is an organic polymer of nylon that has been employed extensively for nearly 30 years in augmentation for a variety of facial deformities. It is an extremely reliable material with a paucity of reported adverse reactions. On implantation, histologic examination has shown that it elicits a moderate foreign body reaction. Subsequent microscopic studies show a mild granuloma formation with an influx of macrophages and fibroblasts. Over the ensuing several weeks, the implant is surrounded and infiltrated with fibrous tissue. This anchors and fixes the implant, allowing it to withstand moderate trauma and movement and precludes the common extrusion phenomena seen in solid alloplastic implants. I have personally performed in excess of 700 procedures employing this material. I believe that it is an excellent choice of an augmentation material, particularly for the nasal dorsum and the mentum. It can be used de novo for primary augmentation or as an autoalloplastl~2in complex defects or when carving or more structural support is needed. In my experience it has excellent survival characteristics, resisting extrusion, and requires removal in less than 1.5% of cases. In this article the application and techniques of polyamide mesh for nasal dorsal augmentation and mentoplasty are discussed.
NASAL DORSAL AUGMENTATION Augmentation of the nasal dorsum is a frequent reconstruction need encountered by the facial plastic surgeon. Saddle nose deformity is typically seen
after trauma or a surgical misadventure. It may result from excessive hump reduction or radical septa1 surgery. However, in the my experience nasal augmentation is more commonly employed in the black or platyrrhine nose where there is commonly a deficiency in the nasal dorsum. The tightly rolled polyamide mesh is ideally suited for dorsal augmentation. It's capacity for fibrous tissue ingrowth ensures that it is fixed, has the ability to withstand motion, and possesses a tolerance to withstand the minor to moderate nasal trauma. These characteristics make it ideally suited for nasal augmentation, which usually extends caudal into the mobile portion of the nose. For these reasons, it is my nasal augmentation material of choice. The method used in fashioning the implant is identical for all de novo uses. The mesh is folded into two or four simple layers approximately the width of the desired length of the prosthesis. The diameter required dictates the amount of mesh to be rolled. The folded mesh is then folded lengthwise, which decreases the distance to be rolled by a half. The material is rolled as tightly as possible. The failure to do this may explain why some have significant resorption. On completion, the rolled mesh is grasped firmly on one end by the operator and on the other end by the assistant. A 4-0 Supramid or nylon suture is then placed 5 mm from one end and the free margin of the mesh is then sutured to the roll with a continuous stitch stopping 5 mm from the opposite end, at which point the sutures are tied. Care is taken not to run the suture all the way to the end, since in cutting the prosthesis to size the suture
Department of Otolaryngology, Louisiana State University Medical Center School of Medicine, Shreveport, Louisiana Reprint requests: Dr. Stucker, Louisiana State University Medical Center, PO. Box 33932, Shreveport, LA 71130-3932 Copyright 01992 by T h ~ e m eMedical Publishers, Inc., 381 Park Avenue South, New Yurk, NY 10016. All rights reserved
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Fred Stuckev, M . D., Frank Wong, M . D., and Gary Shaw, M . D.
FACIAL PLASTIC SURGERY Volume 8, Number 3 July 1992
A standard rhinoplasty dressing is utilized. Antibiotics are prescribed for 7 days. MENTOPLASTY A significant percentage of rhinoplasty candidates will not realize optimal results without an adjunctive mentoplasty. Our experience has been that approximately one of four cosmetic rhinoplasty patients would benefit from such a procedure. In this context we are not addressing those patients with a significant mandibular retrusion who are better treated by an orthognathic procedure. However, the common retrusive chin deformities is actually accentuated after rhinoplasty. Although the number of patients aware of augmentation chin surgery is increasing, most rhinoplasty candidates with a retrusive chin do not present with an appreciation of the potential benefits to be gained by an adjunctive augmentation mentoplasty. It is therefore incumbent on the facial plastic surgeon to discuss this and other adjunctive procedures with all potential candidates. Many materials can be employed successfully in mentoplasty. It is one of the more ideal areas for implanting alloplastic materials. The pocket is developed over a firm skeletal structure, which is covered by a generous bulk of protective soft tissue. Finally, it is in an area that is relatively immobile, although the mandible moves, the implant is quite stable. We prefer the tightly rolled polyamide mesh, since it is naturally incorporated with host fibrous tissue rather that encapsulated, as are all solid synthetic materials. Because of this quality, extrusion is extremely unlikely and infections are very rare. I have performed 300 chin operations over the past 15years and none has been lost. Seven infections occurred, but all implants were salvaged following antibiotic and expectant wound care. No instance of infection has
Figure 1. A: Orientation of retractor and bayonet for placement of implant. B: Grasping implant through skin after withdrawing bayonet to ensure implant remains in proper position.
184
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could inadvertently be severed and cause the roll to unravel. The implant is then shaped or tapered on the ends with a Mayo scissors and placed in a solution of the antibiotic lincomycin. The superior aspect of the nasal implant must be tapered to fit well into the nasofrontal angle. Tissue fixation in this region ensures that the implant will not fall and cause tip ptosis. The rolled implant fixes in the nasofrontal angle and actually maintains tip projection. The inferior end is designed so that it is superior to and slightly overlaps the cephalic margins of the lower lateral cartilages. The degree of augmentation possible is totally dependent on and may not exceed the tip projection achieved in order to prevent a rounded, doughy tip. In the absence of other considerations, either an external rhinoplasty or a marginal incision technique is generally used, thus avoiding transcartilaginous or intercartilaginous incisions, which would allow the implant to lie in immediate proximity to the incision. The receipient site must be free of any tissue bands or attachments, enabling the implant to be placed easily without becoming distorted. Proper positioning and placement is facilitated by utilizing an Aufrict retractor for exposure and a bayonet forceps to place and position the implant. The implant is grasped with the bayonet prongs in a vertical orientation so that the upper tine rides unimpeded along the undersurface of the Aufrict retractor. Once in proper position, the elevator is withdrawn. The thumb and index finger of the alternate hand grasp the implant through the dorsal skin and the bayonet forceps is withdrawn (Fig. 1).Inspection and palpation ensure proper sizing and positioning. No fixation sutures are necessary when a proper size pocket is made. The endonasal incisions are closed with a 5-0 chromic suture and columnella incision of the open rhinoplasty are with 6-0 nylon. Nasal packing is unnecessary and detrimental and thus is avoided.3
FACIAL AUGMENTATION WITH ROLLED ALLOPLASTIC MESH-Stucker,
d .
.
Figure 3.
Double edged scissors developing pocket for
implant.
properly on the mandible, and an oversized pocket may predispose to skewed placement, hematoma To ensure proper placement, the implant orienta- formation, or the potential for subsequent malaligntion is marked on the skin. The most important ment of the implant. To ensure a proper dissected coordinates are a vertical line marking the apparent recipient site, the pocket is examined with the nasal midline of the chin as it relates to the face and a speculum or Aufrict elevator and all remaining tishorizontal line oriented along the maximal projec- sue bands are severed with the scalpel (Fig. 4). Once created, the implant site is packed with a surgical tion of the arch of the mandible (Fig. 2). The region is locally infiltrated with approxi- sponge and attention is turned to fashioning the mately 3 cc of 1% lidocaine with 1:100,000 of epi- implant (Fig. 5). As with the nasal implant, the mesh nephrine. It is important not to distort the area by is tightly rolled to the desired circumference or thickballooning the mentum with anesthetic solution. An ness and secured as previously described with a incision of 1.5 to 2 cm is made in the submental running 4-0 Supramid suture. Both ends of the imcrease. Sharp dissection is carried through skin and plant are tapered and it is placed in the lincomycin subcutaneous tissue to the mandible. A scissor is solution. Once soaked, excess solution is squeezed first used by spreading to develop a pocket over the out and with the aid of either a nasal speculum or mandible and a knife completes the dissection and is Aufrict retractor the pocket is exposed and the imnecessary to sever all tissue bands, thus allowing the implant to lie flat (Fig. 3). The periosteum is not violated. Care is taken to avoid injury to the mental nerves and dissection must be of adjusted so that the dimensions exactly accommodate the implant. An undersized pocket prevents the implant from lying
TECHNIQUE
Figure 2.
Vertical and horizontal skin markings.
Figure 4.
Dissected pocked packed with gauze.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
resulted in the past 9 years since the practice of soaking the implants in lincomycin solution. An infection did occur in a combination submental lipectomy and augmentation mentoplasty but the implant area, which was separated from the neck wound with a subcutaneous closure, was not inflamed. Once the mesh is incorporated with fibrous tissue, it is permanently fixed. This eliminates the potential for migration, dislocation, and late extrusion inherent with solid synthetic implants. Additionally solid implants have been shown to erode bone, but this has not been the case with the rolled mesh. Another favorable characteristic of incorporated mesh is that it possesses a more natural feel to both the surgeon and the patient once the healing process has passed.
Wong, Shaw
FACIAL PLASTIC SURGERY Volume 8, Number 3 July 1992
Figure 5.
Mesh rolled, sutured and ends tapered.
plant is positioned. It must lie flat without evidence of bunching or curling. The retractor is removed and the chin is examined at all angles and digitally palpated for proper size and positioning. Once satisfied, the wound is closed in two layers using a 4-0 chromic subcutaneous layer and a running 6-0 nylon for skin. Paper tape or other adhesive material is applied after applying tincture of benzoin. The first strip of one-half inch paper tape is placed directly over the implant and arch of the mandible in a posterior direction. The next strip of tape is applied just beneath the incision under the chin and directed superiorly and laps over the first tape. Four to six additional strips are applied in a tiered fashion alternating directions, as was done in the first and second tapes. Postoperatively, patients are given oral antibiotics for 1 week, talking is limited, and a mechanically soft diet is also advised to avoid excessive jaw motion.
Once the decision to use the autoalloplastis made, the rolled mesh is implanted over the mastoid process. The timing is related to the reconstructive endeavor and may be at the time of removal of another implant for whatever reason (usually infection) or electively 6 to 10 weeks prior to the second stage. As previously described, the mesh is rolled tightly in multilayers and secured with a 4-0 nylon or Supramid suture. It is then immersed in lincomycin. The recipient site is then prepared. A V-shaped incision is made above the hairline in the mastoid region. The incision is carried down to but not through the periosteum. Undermining is carried out in this plane sufficiently to accommodate the implant. Absolute hemostasis is not necessary because a little blood speeds the fibrous ingrowth into the implant. Excessive bleeding or hematoma formation is prevented by the application of a mastoid type dressing postoperatively. The V-shaped flap facilitates harvesting, which is scheduled 6 to 10 weeks after implantation. The incision is closed with a 4-0 chromic suture. All implants when harvested had histologic evidence of complete host tissue incorporation by fibrous ingrowth (Fig. 6). After harvest of the implant, it is easily carved with a scalpel (Fig. 7). The roll can also be partially incised longitudinally, keeping a 2 mm hinge, thus nearly doubling the size of the opened graft. In over 100 grafts only one has required removal for infection. It is, however, much more resistant to trauma and infection. This implant is much firmer and can contribute to structural support. It can also easily be curved for use where a simple tubular implant is not applicable (Fig. 8).
AUTO-ALLOPLAST The previous discussion employs the polyamide mesh in a de novo single-stage procedure. Occasionally though, this may not be an optimum procedure. When a complex defect is encountered or the a required shaping is not possible with rolled mesh, I we employ an alternative method of using polyamide mesh. This situation occurs because Supramid mesh is not able to be carved nor does it offer , structural support. In these instances a firmer material is necessary. Additionally, in multiple revision surgery a relatively avascular area may be encountered. Optimally, one would prefer autogenous tissues that would be recognized as self to minimize the chain of tissue reaction. Because of its property of allowing ingrowth fibrous tissue in its interstices, Supramid can be used as an autoallograph in a twostage~rocedure.Theoretically,theim~lantshould Figure6. Lowpowerh~stolog~csect~ondernonstrat~ng f~brous~ncorporat~on. possess autogenous graft characteristics.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
METHOD
Figure 7.
Wong, Shaw
A: Harvested fibrous incorporated implant. B: Carving of harvested fibrous incorporated auto-
alloplasty.
This indicates that this material possesses a high degree of predictability and reliability when utilized in a prudent manner. We continue to employ the polyamide mesh routinely and strongly recommend it.
REFERENCES
Figure 8. Carved implant for augmentation of severe saddle deformity.
CONCLUSION Polyamide mesh is a versatile nylon polymer whose application in facial plastic surgery has been well documented over the past 20 years. It is used primarily for augmentation of the nasal dorsum and the retrusal chin. As an autoalloplast, it can be employed in the correction of other complex defects. In my extensive experience of nearly 700 cases of employing this material, there have been seven failures.
Stucker FJ: Auto-alloplast: A contemporary concept in facial Implantation. Facial Plast Surg 3:137-139, 1986 Stucker FJ: Auto-alloplast, an experimental and clinical study. Arch Otolaryngol 108:130, 1982 Stucker FJ: Case against nasal packing. Laryngoscope 1977. Adams JS: Grafts and implants in nasal and chin augmentation. Otolaryngol Clin North Am 20:913-930, 1987 Adams JS, Feurerstein SS: Looking under the epidermis: A histologic shtdy of implants. In: Ward P, Berman WE (eds): Plastic and Reconstructive Surgery of the Head and Neck, vol. 1. Proceedings of the 4th International Symposium. St. Louis: C.V. Mosby, 1984, pp 148-155 Beekhuis G: Augmentation mentoplasty using polyamide mesh. Layngoscope 86:1602-1605, 1976 Beekhuis G: Saddle deformity: Etiology, prevention and treatment: Augmentation rhinoplasty with polyamide. Laryngoscope 84:2-4, 1974 Simons RF: Adjunctive measures in rhinoplasty. Otolaryngo1 Clin North Am 8:717-740, 1975 Stucker FJ: Mentoplasty using rolled polyamide mesh. Facial Plast Surg 3:107-111, 1986 Stucker FJ: Use implantation in facial deformities. Laryngoscope 87:1523-1527, 1977 Stucker FJ, Hirrokowa RH,Bryarly RC: Technical aspects of facial contouring using polyamide mesh. Otolaryngol Clin North Am 15:123-131, 1982
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
FACIAL AUGMENTATION WITH ROLLED ALLOPLASTIC MESH-Stucker,
NASAL DORSAL AUGMENTATION Augmentation of the nasal dorsum is a frequent reconstruction need encountered by the facial plastic surgeon. Saddle nose deformity is typically seen
after trauma or a surgical misadventure. It may result from excessive hump reduction or radical septa1 surgery. However, in the my experience nasal augmentation is more commonly employed in the black or platyrrhine nose where there is commonly a deficiency in the nasal dorsum. The tightly rolled polyamide mesh is ideally suited for dorsal augmentation. It's capacity for fibrous tissue ingrowth ensures that it is fixed, has the ability to withstand motion, and possesses a tolerance to withstand the minor to moderate nasal trauma. These characteristics make it ideally suited for nasal augmentation, which usually extends caudal into the mobile portion of the nose. For these reasons, it is my nasal augmentation material of choice. The method used in fashioning the implant is identical for all de novo uses. The mesh is folded into two or four simple layers approximately the width of the desired length of the prosthesis. The diameter required dictates the amount of mesh to be rolled. The folded mesh is then folded lengthwise, which decreases the distance to be rolled by a half. The material is rolled as tightly as possible. The failure to do this may explain why some have significant resorption. On completion, the rolled mesh is grasped firmly on one end by the operator and on the other end by the assistant. A 4-0 Supramid or nylon suture is then placed 5 mm from one end and the free margin of the mesh is then sutured to the roll with a continuous stitch stopping 5 mm from the opposite end, at which point the sutures are tied. Care is taken not to run the suture all the way to the end, since in cutting the prosthesis to size the suture
Department of Otolaryngology, Louisiana State University Medical Center School of Medicine, Shreveport, Louisiana Reprint requests: Dr. Stucker, Louisiana State University Medical Center, PO. Box 33932, Shreveport, LA 71130-3932 Copyright 01992 by T h ~ e m eMedical Publishers, Inc., 381 Park Avenue South, New Yurk, NY 10016. All rights reserved
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Fred Stuckev, M . D., Frank Wong, M . D., and Gary Shaw, M . D.
FACIAL PLASTIC SURGERY Volume 8, Number 3 July 1992
A standard rhinoplasty dressing is utilized. Antibiotics are prescribed for 7 days. MENTOPLASTY A significant percentage of rhinoplasty candidates will not realize optimal results without an adjunctive mentoplasty. Our experience has been that approximately one of four cosmetic rhinoplasty patients would benefit from such a procedure. In this context we are not addressing those patients with a significant mandibular retrusion who are better treated by an orthognathic procedure. However, the common retrusive chin deformities is actually accentuated after rhinoplasty. Although the number of patients aware of augmentation chin surgery is increasing, most rhinoplasty candidates with a retrusive chin do not present with an appreciation of the potential benefits to be gained by an adjunctive augmentation mentoplasty. It is therefore incumbent on the facial plastic surgeon to discuss this and other adjunctive procedures with all potential candidates. Many materials can be employed successfully in mentoplasty. It is one of the more ideal areas for implanting alloplastic materials. The pocket is developed over a firm skeletal structure, which is covered by a generous bulk of protective soft tissue. Finally, it is in an area that is relatively immobile, although the mandible moves, the implant is quite stable. We prefer the tightly rolled polyamide mesh, since it is naturally incorporated with host fibrous tissue rather that encapsulated, as are all solid synthetic materials. Because of this quality, extrusion is extremely unlikely and infections are very rare. I have performed 300 chin operations over the past 15years and none has been lost. Seven infections occurred, but all implants were salvaged following antibiotic and expectant wound care. No instance of infection has
Figure 1. A: Orientation of retractor and bayonet for placement of implant. B: Grasping implant through skin after withdrawing bayonet to ensure implant remains in proper position.
184
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
could inadvertently be severed and cause the roll to unravel. The implant is then shaped or tapered on the ends with a Mayo scissors and placed in a solution of the antibiotic lincomycin. The superior aspect of the nasal implant must be tapered to fit well into the nasofrontal angle. Tissue fixation in this region ensures that the implant will not fall and cause tip ptosis. The rolled implant fixes in the nasofrontal angle and actually maintains tip projection. The inferior end is designed so that it is superior to and slightly overlaps the cephalic margins of the lower lateral cartilages. The degree of augmentation possible is totally dependent on and may not exceed the tip projection achieved in order to prevent a rounded, doughy tip. In the absence of other considerations, either an external rhinoplasty or a marginal incision technique is generally used, thus avoiding transcartilaginous or intercartilaginous incisions, which would allow the implant to lie in immediate proximity to the incision. The receipient site must be free of any tissue bands or attachments, enabling the implant to be placed easily without becoming distorted. Proper positioning and placement is facilitated by utilizing an Aufrict retractor for exposure and a bayonet forceps to place and position the implant. The implant is grasped with the bayonet prongs in a vertical orientation so that the upper tine rides unimpeded along the undersurface of the Aufrict retractor. Once in proper position, the elevator is withdrawn. The thumb and index finger of the alternate hand grasp the implant through the dorsal skin and the bayonet forceps is withdrawn (Fig. 1).Inspection and palpation ensure proper sizing and positioning. No fixation sutures are necessary when a proper size pocket is made. The endonasal incisions are closed with a 5-0 chromic suture and columnella incision of the open rhinoplasty are with 6-0 nylon. Nasal packing is unnecessary and detrimental and thus is avoided.3
FACIAL AUGMENTATION WITH ROLLED ALLOPLASTIC MESH-Stucker,
d .
.
Figure 3.
Double edged scissors developing pocket for
implant.
properly on the mandible, and an oversized pocket may predispose to skewed placement, hematoma To ensure proper placement, the implant orienta- formation, or the potential for subsequent malaligntion is marked on the skin. The most important ment of the implant. To ensure a proper dissected coordinates are a vertical line marking the apparent recipient site, the pocket is examined with the nasal midline of the chin as it relates to the face and a speculum or Aufrict elevator and all remaining tishorizontal line oriented along the maximal projec- sue bands are severed with the scalpel (Fig. 4). Once created, the implant site is packed with a surgical tion of the arch of the mandible (Fig. 2). The region is locally infiltrated with approxi- sponge and attention is turned to fashioning the mately 3 cc of 1% lidocaine with 1:100,000 of epi- implant (Fig. 5). As with the nasal implant, the mesh nephrine. It is important not to distort the area by is tightly rolled to the desired circumference or thickballooning the mentum with anesthetic solution. An ness and secured as previously described with a incision of 1.5 to 2 cm is made in the submental running 4-0 Supramid suture. Both ends of the imcrease. Sharp dissection is carried through skin and plant are tapered and it is placed in the lincomycin subcutaneous tissue to the mandible. A scissor is solution. Once soaked, excess solution is squeezed first used by spreading to develop a pocket over the out and with the aid of either a nasal speculum or mandible and a knife completes the dissection and is Aufrict retractor the pocket is exposed and the imnecessary to sever all tissue bands, thus allowing the implant to lie flat (Fig. 3). The periosteum is not violated. Care is taken to avoid injury to the mental nerves and dissection must be of adjusted so that the dimensions exactly accommodate the implant. An undersized pocket prevents the implant from lying
TECHNIQUE
Figure 2.
Vertical and horizontal skin markings.
Figure 4.
Dissected pocked packed with gauze.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
resulted in the past 9 years since the practice of soaking the implants in lincomycin solution. An infection did occur in a combination submental lipectomy and augmentation mentoplasty but the implant area, which was separated from the neck wound with a subcutaneous closure, was not inflamed. Once the mesh is incorporated with fibrous tissue, it is permanently fixed. This eliminates the potential for migration, dislocation, and late extrusion inherent with solid synthetic implants. Additionally solid implants have been shown to erode bone, but this has not been the case with the rolled mesh. Another favorable characteristic of incorporated mesh is that it possesses a more natural feel to both the surgeon and the patient once the healing process has passed.
Wong, Shaw
FACIAL PLASTIC SURGERY Volume 8, Number 3 July 1992
Figure 5.
Mesh rolled, sutured and ends tapered.
plant is positioned. It must lie flat without evidence of bunching or curling. The retractor is removed and the chin is examined at all angles and digitally palpated for proper size and positioning. Once satisfied, the wound is closed in two layers using a 4-0 chromic subcutaneous layer and a running 6-0 nylon for skin. Paper tape or other adhesive material is applied after applying tincture of benzoin. The first strip of one-half inch paper tape is placed directly over the implant and arch of the mandible in a posterior direction. The next strip of tape is applied just beneath the incision under the chin and directed superiorly and laps over the first tape. Four to six additional strips are applied in a tiered fashion alternating directions, as was done in the first and second tapes. Postoperatively, patients are given oral antibiotics for 1 week, talking is limited, and a mechanically soft diet is also advised to avoid excessive jaw motion.
Once the decision to use the autoalloplastis made, the rolled mesh is implanted over the mastoid process. The timing is related to the reconstructive endeavor and may be at the time of removal of another implant for whatever reason (usually infection) or electively 6 to 10 weeks prior to the second stage. As previously described, the mesh is rolled tightly in multilayers and secured with a 4-0 nylon or Supramid suture. It is then immersed in lincomycin. The recipient site is then prepared. A V-shaped incision is made above the hairline in the mastoid region. The incision is carried down to but not through the periosteum. Undermining is carried out in this plane sufficiently to accommodate the implant. Absolute hemostasis is not necessary because a little blood speeds the fibrous ingrowth into the implant. Excessive bleeding or hematoma formation is prevented by the application of a mastoid type dressing postoperatively. The V-shaped flap facilitates harvesting, which is scheduled 6 to 10 weeks after implantation. The incision is closed with a 4-0 chromic suture. All implants when harvested had histologic evidence of complete host tissue incorporation by fibrous ingrowth (Fig. 6). After harvest of the implant, it is easily carved with a scalpel (Fig. 7). The roll can also be partially incised longitudinally, keeping a 2 mm hinge, thus nearly doubling the size of the opened graft. In over 100 grafts only one has required removal for infection. It is, however, much more resistant to trauma and infection. This implant is much firmer and can contribute to structural support. It can also easily be curved for use where a simple tubular implant is not applicable (Fig. 8).
AUTO-ALLOPLAST The previous discussion employs the polyamide mesh in a de novo single-stage procedure. Occasionally though, this may not be an optimum procedure. When a complex defect is encountered or the a required shaping is not possible with rolled mesh, I we employ an alternative method of using polyamide mesh. This situation occurs because Supramid mesh is not able to be carved nor does it offer , structural support. In these instances a firmer material is necessary. Additionally, in multiple revision surgery a relatively avascular area may be encountered. Optimally, one would prefer autogenous tissues that would be recognized as self to minimize the chain of tissue reaction. Because of its property of allowing ingrowth fibrous tissue in its interstices, Supramid can be used as an autoallograph in a twostage~rocedure.Theoretically,theim~lantshould Figure6. Lowpowerh~stolog~csect~ondernonstrat~ng f~brous~ncorporat~on. possess autogenous graft characteristics.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
METHOD
Figure 7.
Wong, Shaw
A: Harvested fibrous incorporated implant. B: Carving of harvested fibrous incorporated auto-
alloplasty.
This indicates that this material possesses a high degree of predictability and reliability when utilized in a prudent manner. We continue to employ the polyamide mesh routinely and strongly recommend it.
REFERENCES
Figure 8. Carved implant for augmentation of severe saddle deformity.
CONCLUSION Polyamide mesh is a versatile nylon polymer whose application in facial plastic surgery has been well documented over the past 20 years. It is used primarily for augmentation of the nasal dorsum and the retrusal chin. As an autoalloplast, it can be employed in the correction of other complex defects. In my extensive experience of nearly 700 cases of employing this material, there have been seven failures.
Stucker FJ: Auto-alloplast: A contemporary concept in facial Implantation. Facial Plast Surg 3:137-139, 1986 Stucker FJ: Auto-alloplast, an experimental and clinical study. Arch Otolaryngol 108:130, 1982 Stucker FJ: Case against nasal packing. Laryngoscope 1977. Adams JS: Grafts and implants in nasal and chin augmentation. Otolaryngol Clin North Am 20:913-930, 1987 Adams JS, Feurerstein SS: Looking under the epidermis: A histologic shtdy of implants. In: Ward P, Berman WE (eds): Plastic and Reconstructive Surgery of the Head and Neck, vol. 1. Proceedings of the 4th International Symposium. St. Louis: C.V. Mosby, 1984, pp 148-155 Beekhuis G: Augmentation mentoplasty using polyamide mesh. Layngoscope 86:1602-1605, 1976 Beekhuis G: Saddle deformity: Etiology, prevention and treatment: Augmentation rhinoplasty with polyamide. Laryngoscope 84:2-4, 1974 Simons RF: Adjunctive measures in rhinoplasty. Otolaryngo1 Clin North Am 8:717-740, 1975 Stucker FJ: Mentoplasty using rolled polyamide mesh. Facial Plast Surg 3:107-111, 1986 Stucker FJ: Use implantation in facial deformities. Laryngoscope 87:1523-1527, 1977 Stucker FJ, Hirrokowa RH,Bryarly RC: Technical aspects of facial contouring using polyamide mesh. Otolaryngol Clin North Am 15:123-131, 1982
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
FACIAL AUGMENTATION WITH ROLLED ALLOPLASTIC MESH-Stucker,
