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WARNING: This page may contain scientific photos of live surgeries. THIS SITE IS ONLY FOR DOCTORS !!! WRINKLE THREADING OF THE NASOLABIAL FOLDS WITH GORE-TEX Ziya Saylan, M.D. Düsseldorf, Germany Abstract: A face lift does not have a large effect on the Nasolabial folds, and some modality of treatment other than a face lift must be considered. We have been using expanded polytetrafluorethylene (Gore-Tex® ) implants during the past three years to eliminate the nasolabial folds. This permanent implant is well tolerated by human tissue and has been used as a soft tissue filling material since decades. After the recent introduction of Gore - Tex ® SAM ( Subcutaneous Augmentation Material ) with a built-in trocar we could use SAM also for our purposes. Both methods showed results in the form of palpable string-formed granulations at the nasolabial folds which was not always acceptable for the Patients. Instead of a thick Gore - Tex string sold from the manufacturer under the name of SAM, we are taking Gore - Tex Suture CV-O and loading it to a straight sharp needle as a bundle of strings ( 12 to 20 of them) and implanting it under the fold. This article describes the special application of the Gore -Tex® in to the Nasolabial folds and also results without any palpable granulations at the place of Augmentation. Although the rotation SMAS - platysma bi-directional operation and the subperiostal face lift ( Hamra1 ) does enhance the correction of the nasolabial fold because of the more optimal vector of tightening of the midface, many folds in the face will reappear within the first year after the surgery. For this reason instead of a lifting, filling the folds with an augmentation material is necessary. Expanded polytetrafluorethylene ( Gore - Tex® ) is the newest implant material in facial cosmetic surgery. This permanent implant is an expanded, microporous, polytetrafluorethylene polymer composed entirely of polytetrafluorethylene nodes interconnected by thin fibrils. Fibril length determines the pore size of the material which is filled with air. The pore size can range from 0,5 µ to 30 µ. The pore size is an important factor in influencing the degrees of incorporation of the material to the surrounding tissue ( Neel 2 ). Since 1971 Gore- Tex is used in general, cardio - vascular, urogynecologic and reconstructive surgery as an surgical material with minimal tissue reactions, without any known allergy and very small risk of infections ( % 2,6 ). An ideal augmentations material has to be easy to obtain, easily implanted and removable from the soft tissue without any difficulty. It must be also nonallergic and cheap in price. All such positive qualities are present in our substance Gore-Tex®. Another advantage is, it can be applied immediately without any skin tests. We have applied Gore-Tex ® in about 115 cases in three techniques: In the first method we used ( tied strips method ) Gore-Tex self - cut in customized strips tied to a pull - through suture material from 10 cm to 5 cm big Gore-Tex patches applied via a trocar ( Schoenrock & Reppucci 3 ), the second technique was the SAM method, which means ready manufactured trocars with 2 mm thick and 15 cm long Gore-Tex® strings and the third method was the ours (Gore-Tex Threading method) with a separate needle and a bunch of Gore - Tex ® strings implanted to the nasolabial fold. All three methods were done with the closed technique. Technique : It is a simple procedure with no instrumentation required. Gore - Tex's physical properties has enabled the use of it as an ideal augmentations material for the nasolabial folds because it produces permanent augmentation with no irregularities, and is superior to fat injections, skin implantations, and collagen injections ( Schoenrock 3). The standard procedure to prepare the needle with the Gore-Tex bundle of strings is follows. (1) Take a packet of Gore - Tex suture ( string ) CV-O, 48 inches long. (2) Cut the needles out from the string. (3) Fold the string twice, so that you have four strings each with a length of 12 inches. (4) Thread two strings into a straight sharp needle (for example : Eye-needle straight - cutting EKS-2, Ethicon Inc.) and now you have four strings each six inches long. This will be your material for the nasolabial wrinkle threading or augmentation material for the lips. No incision or suturing is necessary. The needle will be stuck into the lip-mucosa or skin at the nasolabial fold with an angle of 45 degrees. After entering under the nasolabial fold subcutaneously the needle or trocar has to be moved sideways ( windshield-wiper-motion ) in order to cut the fibrous septae which forms the nasolabial fold. After putting the string subcutaneously the skin has to be squeezed together so that the Gore - Tex® string can disappear under the skin as you cut the string and stretch the skin.
This is a very important procedure and the best way to sink the string under the skin, if it is not sunk, there will be fistulas and infections which will cause big problems. Results: 115 patients had Gore - Tex® implantation in to the nasolabial folds, 47 patients with tied strips method ( Schoenrock ), 24 patients with SAM method and the rest 44 with Gore - Tex® threading method. The evaluation of the skin was in all three groups satisfactory, infection was observed only at the first group with tied strips which can be explained with the prolonged time of the surgery and using many instruments. The rate of infection was in the first group 2,1 percent (one case). Arzt and Dinner4 have also observed no infections in their Gore-Tex study in compare to Konrad5 who mentions an infection rate of 3,6%. The indication to remove the Gore-Tex implant in our cases was implant looking out of the skin which forced us to remove the implants as a prophylactic matter against infection. Both patients had new implants after 3 weeks without any further complications. Our explanation for this problem was the large amount of local anesthesia Conclusion: This method of Gore - Tex threading of the nasolabial folds requires no special instruments and at the same time instead of expensive materials it was possible for us to develop our own implant without any high expenses7. All we had to have was a Gore - Tex suture CV - O, 48 inches long, and to thread it in to a straight cutting needle and implant it. During the implantation it was possible to cut off the fibrotic bands between the skin and the fascia by means of moving the sharp needle sideways which additionally eliminated the nasolabial fold. Another advantage of this method is, that in the past it was possible for the Patients to palpate the string because of its thickness (especially the self-cut Gore-Tex®-Patch was very easy to feel under the skin ) . After this new method the Gore-Tex implant is not palpable any more. Also observing no infections without any kind of antibiotic treatment forced us to share these results with our colleagues . REFERENCES
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