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Original Article |

Dacron Implants in Rhinoplasty:  A Review of 136 Cases of Tip and Dorsum Implants FREE

Nabil Fanous, MD, FRCSC; Mark Samaha, MD; Adi Yoskovitch, MD, MSc
[+] Author Affiliations

From the Department of Otolaryngology–Head and Neck Surgery, McGill University, Montreal, Quebec.


From the Department of Otolaryngology–Head and Neck Surgery, McGill University, Montreal, Quebec.

More Author Information
Arch Facial Plast Surg. 2002;4(3):149-156. doi:.
Text Size: A A A
Published online

The achievement of successful results in rhinoplasty may require the use of autografts, homografts, or alloplastic materials. Among the alloplasts, Dacron is an easily handled and manipulated synthetic material, readily applicable to nasal augmentation. The following represents the indications, surgical technique, outcome results, and analysis of our experience with Dacron mesh implants to the nasal tip, dorsum, and lateral walls in 136 patients.

Figures in this Article

The goal of an optimal aesthetic result in rhinoplasty may necessitate the use of grafts or implants. The different categories of materials used to achieve this consist of autografts, homografts, and alloplasts. The most common autografts used in rhinoplasty include septal cartilage and bone, conchal cartilage, and costal cartilage and bone. Although preferred by several researchers for their biocompatibility, bone and cartilage autografts may be associated with certain complications, particularly the predictability of the aesthetic result.

Several types of alloplastic materials have been, and continue to be, used for dorsal and tip augmentation in rhinoplasty.1-11 We believe implants have a valuable role in rhinoplasty, provided the right implant material is chosen and the correct technique is used for the proper indication. Some different types of alloplastic implants used in rhinoplasty are as follows: polytetrafluoroethylenes, the most common being Gore-Tex (W. L. Gore Associates, Inc, Flagstaff, Ariz); silicone rubber (such as Silastic); polyethylene, such as Medpore (Porex, Fairburn, Ga) and Plastipore (Richards Manufacturing Company, Memphis, Tenn) and polyesters and polyamides, such as Dacron (Ethicon Inc, Somerville, NJ), Mersilene (Ethicon Inc), Supramid7 (S. Jackson Inc, Alexandria, Va), and the Cooley Dacron knitted implant (Meadox; Boston Scientific, Quincy, Mass). Dacron material implants have been extensively used in cardiovascular surgery, with the results of many long-term follow-up studies reported in the medical literature.12-17 Dacron fabric (Cooley) is a polyethylene terephthalate woven into a tight nonresorbable mesh. It is a multifilament fabric supplied as a white fabric sheet. Its design allows minimal tissue ingrowth that is enough to maintain the implant position. The multifilament arrangement makes the implant not slippery during surgery; therefore, it stays wherever it is placed and almost sticks to its bed or to the overlying skin. In addition, this implant may be handled, cut, and shaped easily while retaining a certain degree of body. It does not shred, as encountered with other Dacron-type materials, such as Mersilene mesh. In addition, its soft nature makes it difficult to detect by skin palpation or visual inspection, even years after being implanted.

One of us (N.F.) reported his experience with 98 cases of tip augmentation using Dacron mesh (Mersilene mesh) in 1991.2 Subsequent to this, our use of Dacron has moved from the looser mesh form (Mersilene) to the fabric form (Cooley) because of the latter's further ease of intraoperative manipulation and minimal shredding. However, this advantage of the fabric form is minimal. As far as clinical results are concerned, both Dacron materials are identical.

We present herein our experience in using Dacron alloplastic materials, mostly the fabric form, to augment and shape the tip, dorsum, and lateral walls in 136 patients undergoing rhinoplasty.

PATIENTS

A retrospective analysis was performed, reviewing the results in 136 patients who underwent rhinoplasty with augmentation using Dacron implants. The indications for dorsum augmentation were a deep nasofrontal angle, a saddle deformity of the dorsum, or a depressed supratip area. Dorsal saddle deformity was the most common indication of dorsal correction.

Indications for tip augmentation were previously detailed.2 The 2 most common indications were a recessed tip and a wide tip.

The implant may also be used in the lateral wall to augment a depression, typically in cases of side-to-side nasal pyramid deviation.

All patients included in this study were asked several months postoperatively to rate their degree of satisfaction with the cosmetic result. The results were graded as very happy (n = 68), happy (n = 59), satisfied (n = 4), and dissatisfied (n = 5). The surgeon, at that same time, rated his own assessment of the aesthetic result. The different grades were very good (n = 64), good (n = 40), satisfactory (n = 24), and unsatisfactory (n = 8).

TECHNIQUE
Tip Augmentation

The technique used for tip implantation was previously described in detail2, 7 by one of us (N.F.). Several critical points and some minor modifications will be emphasized. The fabric material (Cooley) is first folded onto itself to form a pad that is 2 to 8 layers thick and approximately 1 cm in width (from left to right) and 8 mm in height (from superior to inferior). The thickness of each layer is approximately 0.5 mm. Therefore, a 2-layer implant is approximately 1 mm thick, and an 8-layer implant is approximately 4 mm thick. The implant is shaped like either a lozenge (10 mm in width × 7 mm in height) (Figure 1A) or a triangle (10 mm [base] × 5 mm × 5 mm, with the apex pointing downward). The triangular shape is used often in cases of thick nasal skin with poor definition. Depending on the degree of tip recession, 2 to 8 layers (1-4 mm) may be used. Typically, the most common thickness used is 4 to 6 layers. A central through-and-through catgut suture is used to hold the layers together.

Place holder to copy figure label and caption
Figure 1.

Technique of tip augmentation. A, Preoperative planning: the implant contour is marked over the skin of the tip, making sure that line ab of the implant is at the level of the tip-defining point in the profile view. B, Incision. C, Pocket dissection in the frontal and profile views. D, Introduction of the implant in the pocket. E, Making sure line ab (at the end part of the hemostat) is horizontal, then stabilizing gently the upper and lower borders of the hemostat, before opening and retracting it.

Graphic Jump Location

After outlining the position of the implant on the nasal tip preoperatively (Figure 1A), a rim incision of 1.0 to 1.5 cm is made along the caudal border of the right alar cartilage (Figure 1B). Dissection of a subcutaneous pocket, slightly larger than the size of the implant, is then performed (Figure 1C). The implant, soaked in bacitracin solution, is held horizontally with a curved mosquito clamp, making sure that the end of the mosquito clamp is horizontally placed across the implant and that the tip of the instrument is on the left end of the implant (Figure 1D). The implant is then inserted while pulling the right alar rim up using a double-sharp hook and while pushing the alar cartilages down with blunt scissors. The tip of the curved mosquito clamp is positioned at point b under the skin (Figure 1E), and the implant is aligned horizontally over the line ab. The upper and lower parts of the implant are then stabilized gently, with the fingers placed above and below the curved mosquito clamp over the skin; then, the mosquito clamp is widely opened and slowly withdrawn. One 6-0 catgut suture is placed at the midpoint of the incision for approximation.

Dorsum Augmentation

The superior and inferior ends of the long axis of the implant are marked superiorly and inferiorly on the skin of the nose along the midline (Figure 2). In the event the dorsal depression is deeper on one area (typically the middle of the dorsum at the level of the rhinion), a third mark is placed on the skin at that site to identify the area of maximum implant thickness. In general, the length of the implant varies from 2.5 to 3.5 cm, the width from 8 to 10 mm, and the thickness from 2 to 6 layers (1-3 mm). In some instances, the thickness may be greater than 6 layers. The implant may be uniform in thickness or may have an area of greater thickness, as previously indicated. The implant is then shaped in the following manner: the upper and lower ends of the implant are made triangular to ensure a gradual tapering of the implant ends. This avoids an abrupt step deformity after the swelling subsides postoperatively. Also, the implant sides, namely, the left and right borders, are tapered (angled) for the same purpose. If one area of the implant (eg, the central third) is thicker than the rest, a second implant is calculated, measured, and tapered like the first main implant. The shorter implant is then placed under the longer one, and an additional through-and-through catgut suture is used to attach both implants together.

Place holder to copy figure label and caption
Figure 2.

Dorsal and lateral wall implants: the frontal view demonstrates the shape of the implants, their tapered ends, their relative size compared with the pockets, and their central sutures. The access incision to each pocket is marked by heavy dots. The transverse section shows the side beveling of the implants, which is facing outward in the case of a dorsal implant and inward in the case of a lateral wall implant.

Graphic Jump Location

If the dorsal dissection has not been completed, a 1.5-cm incision is made on the medial end of the right intercartilaginous incision at the area of the septal angle (Figure 2). A subcutaneous or supraperichondrial supraperiosteal pocket is dissected along the dorsum. The layers of the prepared dorsal implant are usually sutured about the center or at both ends with 4-0 chromic transfixion sutures to hold the layers together (Figure 2). The implant is then placed between the 2 sides of an angled nasal bayonet forceps, ensuring that the superior end of the implant is exactly at the closed tip of the angled forceps. An Aufricht dorsal retractor is used to elevate the dorsal nasal skin, while a curved mosquito clamp is used to retrieve and pull down on the lower edge of the intercartilaginous incision for better entry (Figure 3). The angled forceps embracing the implant is then introduced slowly within the dorsal skin pocket, sliding against the Aufricht elevator (rather than against the dorsum), until it reaches the upper mark on the nasal skin. The Aufricht retractor is then moved slowly backward and removed. The fingers of the left hand are placed gently on either side of the implant. The angled forceps is opened widely and then slowly retraced backwards, using a gentle rocking motion to avoid implant retraction or displacement during this maneuver. The incision is then inspected to ensure that the lower end of the implant is positioned at least 4 mm away from the closure site. A single 4-0 chromic suture is then used to close the incision.

Place holder to copy figure label and caption
Figure 3.

Introduction of the dorsal implant into the dorsal pocket.

Graphic Jump Location
Lateral Wall Augmentation

An incision is made through one or both intercartilaginous folds, depending on whether the depression is unilateral or bilateral. The implant marking, preparation, and insertion are similar to that described for the dorsum. However, the implant is typically much thinner, varying between 1 and 2 layers (0.5-1.0 mm). For lateral wall augmentation, 50% undercorrection is the rule, as the slightest overcorrection will be extremely noticeable a few months postoperatively. The shape is again triangular and tapered if more than one layer is used.

In rare cases, when the lateral wall depression extends inferiorly beyond the lower border of the upper lateral cartilage, the access incision may be made intracartilaginous through the alar cartilage. This is because the incision to the pocket has to be at least 4 mm inferior to the implant.

This series consisted of 92 women and 44 men, for a male-female ratio of 1:2.1. The mean ± SD age of the patients was 26.5 ± 7.5 years for men and 28.9 ± 9.4 years for women. All rhinoplasties were performed by the same surgeon (N.F.). In 88 (65%) of the 136 procedures, only the tip was augmented, while in 45 (33%) of the patients, the tip and the dorsum or lateral walls were augmented. In 3 instances (2%), Dacron was used on the dorsum only.

All patients were prescribed intraoperative antibiotics: intravenous cefazolin, 1 g, when an allergy to penicillin was ruled out or intravenous erythromycin in the cases of penicillin allergy. All patients were treated with oral antibiotics (such as erythromycin) for 1 week postoperatively for further prophylactic coverage.

The follow-up ranged from 7 months to 12 years (average, 37 months). The same operating surgeon (N.F.) performed the follow-up and assessment. Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, and Figure 10 show examples of preoperative and postoperative results of Dacron implantations in various patients (lateral wall implants in Figure 4; dorsum and supratip implants in Figure 5; implants in a patients who underwent revision rhinoplasty in Figure 6; dorsal implant thickest at the nasofrontal angle superiorly in Figure 7; dorsal implant of equal thickness in Figure 8; tip implant only, representing the most common implant indication, in Figure 9; and long-term results in Figure 10).

Place holder to copy figure label and caption
Figure 4.

A and B, Preoperative views of a 29-year-old man with a narrow bony bridge and concave upper lateral walls more on the left side than on the right, a recessed upper dorsum, thick redundant skin at the supratip and tip areas, and a drooping nasal tip. C and D, Postoperative result 2 years 4 months following a rhinoplasty with lateral wall implants (just 1 layer on the right and 2 on the left) and dorsal and tip implants.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

A and B, Preoperative views of a 29-year-old woman with a low dorsum and thick skin at the tip and supratip. C and D, Postoperative results 11 months following rhinoplasty with a dorsal implant thickest at the supratip area because of a resistant skin concavity at that area. A tip implant was also used.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

A and B, Preoperative photographs of a 20-year-old man with a history of 3 previous septorhinoplasties. He presented with a turned-up asymmetrical tip, a recessed dorsum, and lateral wall depressions, more obvious on the left. C and D, Postoperative results 7 years 2 months following a revision rhinoplasty with dorsal, tip, and left lateral wall Dacron (Ethicon Inc, Somerville, NJ) implants.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

A and B, Preoperative photograph of a 33-year-old man with a recessed ill-defined nasal tip, a low upper dorsum, and very thick nasal skin. C and D, Postoperative results 2 years 10 months following a rhinoplasty with a dorsal implant (thicker at the root of the nose) and a nasal tip implant.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

A and B, Preoperative photographs of a 27-year-old man with a projecting tip and a low dorsum. C and D, Postoperative results 12 months following a rhinoplasty with a dorsal implant of uniform thickness and a tip implant.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

A and B, Preoperative views of a 22-year-old woman who is a typical example of a nose surgery candidate with a dorsal hump and a somewhat wide nasal tip. C and D, Postoperative photographs 15 months after a regular rhinoplasty combined with the placement of a tip implant to achieve a well-defined yet natural-looking nasal tip. This case is a typical example of the use of the Dacron (Ethicon Inc, Somerville, NJ) nasal tip implant, which is more often used in the nasal tip than in the dorsum or lateral walls.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

A and B, Preoperative views of a 28-year-old woman with a low dorsum and a prominent and very boxy nasal tip. C and D, Very long-term postoperative result 11 years 2 months after the use of Dacron (Ethicon Inc, Somerville, NJ) implants in the dorsum and tip areas.

Graphic Jump Location

The most significant complication was infection, which occurred in 9 (6.6%) of the patients. In all cases, the patient was immediately given oral antibiotics on diagnosis of the infection, and the implant was removed under local anesthesia as soon as possible. Removal of the implant was always performed without difficulty because there was little tissue infiltration or fibrous attachment in all of the patients with infection. In the case of a tip implant, a curved mosquito clamp is used to retrieve the implant through a small rim incision. In the case of a dorsal or lateral wall implant infection, the same technique is used through an intercartilaginous incision, but more dissection is required. It is important to accurately count the number of layers removed to ensure complete removal of the implant.

Ten implants were removed in these 9 patients. Eight were tip implants, and 2 were dorsal implants. In a single instance, tip and dorsum implants were removed. In all patients, the infection resolved within days of implant removal. Of the 9 patients, 6 underwent another procedure during which a second Dacron implant was inserted. The remaining 3 patients declined a second surgery. (It has been our experience that after implant removal, the area previously receiving the implant seems to retain a mild degree of augmentation. We have no explanation as to why this happens, but it could theoretically be due to granulation tissue formation as a reaction to the implant or the infection.)

A diagnosis of implant infection was based on purulent discharge at the site of the pocket incision, in addition to one or more of the following signs: swelling, tenderness, redness, or extrusion. The presence of discharge is definite proof of implant infection. In the absence of discharge, the patient is given antibiotics and checked almost daily to rule out the small possibility of a limited skin infection (eg, furuncle) not involving the implant.

Two patients underwent revision because of an unsatisfactory aesthetic result, where a tip implant had migrated slightly to the right and a dorsal implant was too thick. This was remedied under local anesthesia by trimming a portion of the implant, a somewhat tedious procedure. The noninfected implant is usually well attached to the skin and underlying structures. Dissecting the implant off the overlying skin is easier than freeing it from the underlying cartilage or bone. The surgeon may choose 1 of 3 approaches: (1) trim the excess (the hardest to do, because the implant is well integrated and the Cooley fabric is difficult to cut when invaded with granulation tissue); (2) remove the entire implant and replace it with a brand new one (the easiest approach); or (3) remove the implant, reshape it, and reinsert it (the only problem is fixing it in place, because it tends to be slippery).

Dacron fabric allografts are among the myriad of options available in rhinoplastic surgery. Although potential postoperative infection is a disadvantage, Dacron fabric implants are particularly desirable to use in many cases of augmentation rhinoplasty. In terms of the aesthetic result, they have several advantages, the most important of which is having an impressive natural appearance and feel that are hard to detect by either visual examination or manual palpation. They display no tendencies for curling or resorption over time9, 11 and are unlikely to undergo displacement. In our series, no cases of resorption or implant distortion were observed. In addition, there is no donor site morbidity. Dacron fabric can be molded to assume any shape or thickness required, providing a controllable and smooth contour. The amount of available material is unlimited. Decreased surgical time contributes to lower morbidity and lower cost. Finally, Dacron has been used extensively as a cardiovascular implant and has an excellent long-term record.12-17

Other implantable materials commonly used have similar advantages, but certain drawbacks make them less desirable. Silastic, for example, a silicone rubber, has a firm consistency, therefore tending to feel like a foreign body under the skin. Also, it lacks pores, impeding tissue ingrowth and possibly contributing to implant displacement. Its surface is slippery, which may lead to malpositioning and which makes it hard to handle intraoperatively. Gore-Tex, which has been used in nasal augmentation,6-8 also tends to be slippery, causing possible displacement in the initial postoperative period, before tissue ingrowth has taken place. In addition, Gore-Tex has a whitish color, which may become visible externally, particularly in thin-skinned individuals and particularly in the long term after postoperative edema has subsided.

Dacron is not without its drawbacks, the most significant of which is infection.1 Others include asymmetry and incorrect implant volume, both mostly related to the surgeon's experience using the material. This experience is quickly acquired if the guidelines suggested earlier in this article, regarding the implant's thickness range, shape, tapered edges, access incision, and insertion technique, are vigorously followed. The incision needs to be large enough (1.5 cm) to allow good exposure, dissection of a pocket, and easy implant introduction. It should be closed loosely to allow any serous discharge or bleeding to drain, rather than remain confined within the pocket and progress to abscess formation. The pocket needs to be approximately 50% larger than the size of the implant because it will eventually contract. If it is not sufficiently large, it will result in subsequent implant infection or extrusion.

Our complication rate of infection is comparable to previously reported rates of 4% to 9%.4, 7 However, this drawback is tempered by the many advantages associated with the use of this material. The high cosmetic reliability and quality of the result are often understated in the literature. Although cartilage grafts are rarely infected, they have cosmetic problems, including resorption, displacement, curling, and sharp edges. The longer the postoperative follow-up, the more evident some of these problems will become, especially those related to curling and sharp edges and those in medium- to thin-skinned patients.

Accepted for publication January 22, 2002.

We thank Ildico Horvath, medical artist, for her assistance in preparing the figures; Robert Derval, medical photographer, for his photographic contributions; Barbara Armbruster, MA, for her help in editing; Lucie Roy and Stephanie Luetticken, MBA, for organizing the manuscript; and Jackie Griguolo and Derya Atilgan for their typing assistance.

Corresponding author and reprints: Nabil Fanous, MD, FRCSC, Department of Otolaryngology–Head and Neck Surgery, McGill University, 1 Westmount Sq, Suite 1380, Montreal, Quebec, Canada H3Z 2P9.

Constantino  PD. Synthetic biomaterials for soft tissue augmentation in the head and neck. Otolaryngol Clin North Am. 1994;27223- 262
Fanous  N. > Mersilene tip implants in rhinoplasty: a review of 98 cases. Plast Reconstr Surg. 1991;87662- 673
Link to Article
Beckhuis  GJ. Mersilene mesh to augment the nasal bridge. Am J Cosmetic Surg. 1986;349
Colton  JJBeckhuis  GJ. Use of Mersilene mesh in nasal augmentation. Facial Plast Surg. 1992;8149- 156
Link to Article
Mendelsohn  MDunlop  G. Gore-Tex augmentation grafting in rhinoplasty: is it safe?  J Otolaryngol. 1998;27337- 341
Shoenrock  LDChernoff  G. Subcutaneous implantation of Gore-Tex for facial reconstruction. Otolaryngol Clin North Am. 1995;28325- 340
Fanous  NWebster  R. Supramid tip implants in rhinoplasty. Arch Otolaryngol Head Neck Surg. 1987;113728- 736
Link to Article
Lovice  DBMingrone  MDToriumi  DM. Grafts and implants in rhinoplasty and nasal reconstruction.  Otolaryngol Clin North Am. 1999;32113- 141
Link to Article
Silver  WEGoldberg  J. Nasal grafts and implants.  Facial Plast Surg Clin North Am. 1994;2477- 499
Kridel  RWHKraus  WM. Grafts and implants in revision rhinoplasty.  Facial Plast Surg Clin North Am. 1995;3473- 486
Maas  CSMonhian  NShah  SB. Implants in rhinoplasty.  Facial Plast Surg. 1997;13279- 290
Link to Article
Phillips  CEDeWeese  JACampeti  FL. Comparison of peripheral arterial grafts: experimental observations of hemodynamic changes using cineangiography.  Arch Surg. 1961;8258- 68
Link to Article
Szilagyi  DESmith  RFElliott  JPAllen  HM. Long-term behaviour of a Dacron arterial substitute: clinical, roentgenologic and histologic correlations.  Ann Surg. 1965;162453- 477
Link to Article
Cooke  PANobis  PAStoney  RJ. Dacron aortic graft failure. Arch Surg. 1974;108101- 103
Link to Article
Edwards  WS. Arterial grafts of Teflon. Sawyer  PNKaplitt  MJeds.Vascular Grafts. New York, NY Appleton Century Crofts1978;173- 176
Noon  GDeBakey  M.De Bakey Dacron Prosthesis and Filamentous Velour Grafts: Vascular Grafts. New York, NY Appleton Century Crofts1978;177- 184
Edwards  WS. Dilatation and durability changes in synthetic grafts of Dacron and Teflon. Bernhard  VMTowne  JBeds.Complications in Vascular Surgery. New York, NY: Grune & Stratton Inc1980;

Figures

Place holder to copy figure label and caption
Figure 1.

Technique of tip augmentation. A, Preoperative planning: the implant contour is marked over the skin of the tip, making sure that line ab of the implant is at the level of the tip-defining point in the profile view. B, Incision. C, Pocket dissection in the frontal and profile views. D, Introduction of the implant in the pocket. E, Making sure line ab (at the end part of the hemostat) is horizontal, then stabilizing gently the upper and lower borders of the hemostat, before opening and retracting it.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Dorsal and lateral wall implants: the frontal view demonstrates the shape of the implants, their tapered ends, their relative size compared with the pockets, and their central sutures. The access incision to each pocket is marked by heavy dots. The transverse section shows the side beveling of the implants, which is facing outward in the case of a dorsal implant and inward in the case of a lateral wall implant.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Introduction of the dorsal implant into the dorsal pocket.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

A and B, Preoperative views of a 29-year-old man with a narrow bony bridge and concave upper lateral walls more on the left side than on the right, a recessed upper dorsum, thick redundant skin at the supratip and tip areas, and a drooping nasal tip. C and D, Postoperative result 2 years 4 months following a rhinoplasty with lateral wall implants (just 1 layer on the right and 2 on the left) and dorsal and tip implants.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

A and B, Preoperative views of a 29-year-old woman with a low dorsum and thick skin at the tip and supratip. C and D, Postoperative results 11 months following rhinoplasty with a dorsal implant thickest at the supratip area because of a resistant skin concavity at that area. A tip implant was also used.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

A and B, Preoperative photographs of a 20-year-old man with a history of 3 previous septorhinoplasties. He presented with a turned-up asymmetrical tip, a recessed dorsum, and lateral wall depressions, more obvious on the left. C and D, Postoperative results 7 years 2 months following a revision rhinoplasty with dorsal, tip, and left lateral wall Dacron (Ethicon Inc, Somerville, NJ) implants.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

A and B, Preoperative photograph of a 33-year-old man with a recessed ill-defined nasal tip, a low upper dorsum, and very thick nasal skin. C and D, Postoperative results 2 years 10 months following a rhinoplasty with a dorsal implant (thicker at the root of the nose) and a nasal tip implant.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

A and B, Preoperative photographs of a 27-year-old man with a projecting tip and a low dorsum. C and D, Postoperative results 12 months following a rhinoplasty with a dorsal implant of uniform thickness and a tip implant.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

A and B, Preoperative views of a 22-year-old woman who is a typical example of a nose surgery candidate with a dorsal hump and a somewhat wide nasal tip. C and D, Postoperative photographs 15 months after a regular rhinoplasty combined with the placement of a tip implant to achieve a well-defined yet natural-looking nasal tip. This case is a typical example of the use of the Dacron (Ethicon Inc, Somerville, NJ) nasal tip implant, which is more often used in the nasal tip than in the dorsum or lateral walls.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

A and B, Preoperative views of a 28-year-old woman with a low dorsum and a prominent and very boxy nasal tip. C and D, Very long-term postoperative result 11 years 2 months after the use of Dacron (Ethicon Inc, Somerville, NJ) implants in the dorsum and tip areas.

Graphic Jump Location

Tables

References

Constantino  PD. Synthetic biomaterials for soft tissue augmentation in the head and neck. Otolaryngol Clin North Am. 1994;27223- 262
Fanous  N. > Mersilene tip implants in rhinoplasty: a review of 98 cases. Plast Reconstr Surg. 1991;87662- 673
Link to Article
Beckhuis  GJ. Mersilene mesh to augment the nasal bridge. Am J Cosmetic Surg. 1986;349
Colton  JJBeckhuis  GJ. Use of Mersilene mesh in nasal augmentation. Facial Plast Surg. 1992;8149- 156
Link to Article
Mendelsohn  MDunlop  G. Gore-Tex augmentation grafting in rhinoplasty: is it safe?  J Otolaryngol. 1998;27337- 341
Shoenrock  LDChernoff  G. Subcutaneous implantation of Gore-Tex for facial reconstruction. Otolaryngol Clin North Am. 1995;28325- 340
Fanous  NWebster  R. Supramid tip implants in rhinoplasty. Arch Otolaryngol Head Neck Surg. 1987;113728- 736
Link to Article
Lovice  DBMingrone  MDToriumi  DM. Grafts and implants in rhinoplasty and nasal reconstruction.  Otolaryngol Clin North Am. 1999;32113- 141
Link to Article
Silver  WEGoldberg  J. Nasal grafts and implants.  Facial Plast Surg Clin North Am. 1994;2477- 499
Kridel  RWHKraus  WM. Grafts and implants in revision rhinoplasty.  Facial Plast Surg Clin North Am. 1995;3473- 486
Maas  CSMonhian  NShah  SB. Implants in rhinoplasty.  Facial Plast Surg. 1997;13279- 290
Link to Article
Phillips  CEDeWeese  JACampeti  FL. Comparison of peripheral arterial grafts: experimental observations of hemodynamic changes using cineangiography.  Arch Surg. 1961;8258- 68
Link to Article
Szilagyi  DESmith  RFElliott  JPAllen  HM. Long-term behaviour of a Dacron arterial substitute: clinical, roentgenologic and histologic correlations.  Ann Surg. 1965;162453- 477
Link to Article
Cooke  PANobis  PAStoney  RJ. Dacron aortic graft failure. Arch Surg. 1974;108101- 103
Link to Article
Edwards  WS. Arterial grafts of Teflon. Sawyer  PNKaplitt  MJeds.Vascular Grafts. New York, NY Appleton Century Crofts1978;173- 176
Noon  GDeBakey  M.De Bakey Dacron Prosthesis and Filamentous Velour Grafts: Vascular Grafts. New York, NY Appleton Century Crofts1978;177- 184
Edwards  WS. Dilatation and durability changes in synthetic grafts of Dacron and Teflon. Bernhard  VMTowne  JBeds.Complications in Vascular Surgery. New York, NY: Grune & Stratton Inc1980;

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
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