Increasing Your Chances for a Better Outcome
Long after the great Indian surgeon Susruta first worked on soft-tissue augmentation for amputation injuries and nasal reconstruction around 600 BC, surgeons have yet to arrive at a consensus as to the primary choice for nasal implants.
Aside from trauma, surgical nasal reconstruction may be indicated in congenital abnormalities, malignancies, septal perforations, granulomatous disease, syphilis, leishmaniasis, or leprosy if only to restore function and aesthetic appeal.
Rhinoplasty Surgery, or Nose Surgery, has historically involved minimizing the nose by making it thinner, smaller and reducing a nasal hump. Many patients, however, require material to be added in order to improve functionality or the aesthetic appearance of the nose, or both. Asian and African American Rhinoplasty, using nasal augmentation, is used to raise and define a low, depressed nasal bridge or tip. Revision Rhinoplasty often requires nasal augmentation to correct nasal malformation, occurring when a patient's cartilage has been aggressively removed by another surgeon. For others who have experienced severe nasal trauma, the nasal bridge, septum, columella or tip require reconstruction and support of materials to effectively increase functionality as well as improve aesthetic appearance.
The key to successful restoration of the structural and functional integrity of the nasal passage lies in ensuring that the nasal vestibule comprises approximately one half to two thirds of the nasal lobule. To this end, emphasis is on reconstructing the columella, tip, and ala to form an adequate nostril internally while preserving aesthetics externally. In any case, before any surgical intervention is attempted, it is critical to ensure that there is no ongoing infection or conditions warranting further therapy (e.g., serial débridements). Any treatments such as radiation or chemotherapy are best accomplished before and not after nasal implantation. Imaging studies are helpful in indicating available bone stock before using specific devices such as metallic mesh, K-wires, or screws, and are directly correlated with the extent of trauma.
Nasal surgeons have a wide range of choices to select from when nasal augmentation is required for their patient. Which is best for you, the patient? Dr. Slupchynskyj believes one size does not fit all when it comes to nose surgery and specifically when it comes to nasal augmentation. Below, Dr. Slupchynskyj discusses all viable options, their attendant risks and benefits, as well as the surgical considerations to working with each implant.
Nasal implants, for the purposes of augmentation and reconstruction in nose surgery, can be derived from either synthetic (Alloplasts) or natural materials (Autologous/Autogenous). Alloplasts are manufactured from synthetic materials such as silicone, polyethylene (Medpor), expanded polytetrafluoroethylene (ePTFE), and other materials. Autologous grafts are "natural" and are harvested from the patient; cartilage grafts may be harvested from one's own nasal septum, ear, or rib and bone grafts may be used from one's own skull. Homografts are derived from a donor or cadaver.
Dr. Slupchynskyj, a top Rhinoplasty Expert and Face Lift Surgeon in New York and New Jersey, believes Autologous, or natural cartilage implants are the preferred material, specifically nasal septal cartilage (except in cases where the patient's cartilage is insufficient to achieve the required result.
Autogenous cartilage grafts: They are user-friendly, easily available, and biocompatible, firm and flexible, offering structural support. They have decreased resorption rates and low infection rates. While nasal septum, auricular conchal cartilage, and rib are all acceptable donor sites, Septal Cartilage is ideal given its compliance. The conchal auricular cartilage may be used when only small amount of cartilage is required; it is ideal for internal nasal valve grafts and replacement of the lower lateral cartilages.
Septal Cartilage is easily harvested from the same surgical location and causes no additional incisions, however, it is limited and often insufficient for bridge augmentation. This is especially true in African American Rhinoplasty and Asian Rhinoplasty, where a larger amount of implant material is required to sufficiently augment and add volume to a low or depressed nasal bridge.
Another viable and safe Autologous graft is Conchal or Ear Cartilage, which is softer than septal cartilage making it an excellent option adequate for tip reconstruction and support. Ear cartilage is soft, pliable, can be sculpted and the body integrates it well. Like Septal Cartilage, it is not adequate for nasal dorsum bridge elevation due to shape and quantity. Thus, the major limitation of septal and ear cartilages are that they cannot be used to provide adequate structural support in nasal dorsum augmentation.
Additional options for natural or Autologous implant materials are Costal Cartilage, or rib cartilage, and bone grafting. This is particularly important when dorsal augmentation is considered, however, most patients find the additional operative time, recovery and risks associated with harvesting and using costal cartilage and bone unacceptable. Rib cartilage is also predisposed to warping. Operative risks include scarring at the incision site and possible chest wall deformity.
Bone grafts, and specifically Calvarial bone grafts, taken from the outer plate of the skull, are typically used in severely damaged or traumatized noses where the bridge of the nose requires reconstruction and is indicated for functional as well as cosmetic reasons. Bone grafts from split calvarial grafts (cortical bone) and rib have been successfully used to reconstruct total nasal defects and the collapsed nose, with low infection rates. Split calvarial bone grafts may be an excellent substitute when autogenous cartilage is unavailable. Bone chips have been promising in the treatment of the nasal dorsum.
Calvarial Bone Graft harvested from outer table of skull for Nasal Augmentation.
Calvarial Bone removed and ready to carve for Nasal Augmentation and Dorsal Nasal Reconstruction.
Calvarial Bone after Carved for placement in the Nasal Bridge and Nasal Augmentation for support and cosmetic reconstruction.
Before and After placement of Calvarial Bone in the Nasal Dorsum and Nasal Aumentation.
Homografts, otherwise known as donor or cadaver derived cartilage implants are typically irradiated rib cartilage. This cartilage is taken from cadavers or a living human source, which is then processed in order to remove all bacteria and immunogenicity of the material so the patient's body does not reject it. This graft is extremely expensive and we find patients do not readily want donor derived implants due to fear of disease transmission. They manifest typical features of matrix invasion and adjacent connective tissue replacement without donor site morbidity. Irradiated tissue can overcome any challenges of infection, and find ready use in nasal valve collapse or improvement of nasal tip projection. Irradiated homograft costal cartilage has been recommended for correction of contour defects and structural support. Studies suggest that, "irradiated homologous costal cartilage (IHCC) is well tolerated as a grafting material in Rhinoplasty and yields superb functional, structural, and cosmetic results in the most complex and challenging operative cases necessitated by previous unsuccessful nasal surgery, septal perforations, and even in autoimmune diseases that led to nasal deformity." AlloDerm (a LifeCell Corporation, Palo Alto, Calif., product ), an acellular allograft dermal matrix has been employed in lip repairs, nasal reconstructions, and repair of septal perforations.
While natural or Autologous implants remain Dr. Slupchynskyj's preferred material for nasal implants, they are not without their limitations with regard to nasal dorsal augmentation in Asian and ethnic African American Rhinoplasty. In cases where the Septal or Conchal cartilages are not sufficient to add desired volume and excellent structural support for nasal augmentation, Dr. Slupchynskyj prefers to use his customized silastic (silicon) nasal implant, the SLUPimplant™ – it is inert, will not dissolve or degrade over time and can easily be removed without causing additional trauma to the nose, as is often the case with other implants such as the Medpor Implant.
Silicone was the first synthetic implant, or Alloplast, to achieve widespread use in facial plastic surgery. The implant is nonporous and the body surrounds it with a thin capsule after implantation. Medium grade silicone rubber as a columellar strut implant has been successfully used to correct columellar retrusion, improve the nasolabial angle, and increase tip projection by elevating the medial crura of the lower lateral cartilages. Silicone nasal implants for nasal augmentation are available preformed in an "L" shape, which Dr. Slupchynskyj does not ever use. These implants are of one shape and one size. Dr. Slupchynskyj understands and respects the unique features, nasal anatomy, and aesthetic sensibilities of each individual. Preformed implants never address the patient's individuality and needs. For those patients that require more volume and structure than an autologous cartilage implant can offer, Dr. Slupchynskyj's SLUPimplant™ is custom created, and sculpted in a precise manner to fit that patient. Non-customized nasal silastic implants, which are preformed in an "L" shape, result in an elevated nasal bridge, which then also extends to the tip and down through the collumella; a less than ideal location for an Alloplastic/Synthetic implant, as it can lead to extrusion, where the skin over the columella and tip is thin. Since there is movement in this area due to muscle interaction between nose and mouth, pressure is then placed on the nasal tip leading to possible displacement. This pressure, created by the tip of the implant, can diminish blood supply to the skin in the nasal tip, resulting in possible extrusion and skin necrosis. In contrast, Dr. Slupchynskyj's customized silastic implant, is placed over the bridge of the nose with his highly specialized operative technique. The implant is accurately positioned in the correct tissue plane of the nose and then sutured into place.
Removal of "Factory Performed L-Shaped Implant". L-Portion of implant has been cut off for easier removal.
Asian Revision Rhinoplasty – Removal of L-Shaped silicone Implant.
(Left) Asian Revision Rhinoplast y– L-Shaped Silicone Implant causing Pollybeak Deformity and poor naso-frontal angle. (Right) Asian Revision Rhinoplasty–removal of L-Shaped silicone implant replaced with a custom carved silastic implant – SLUPimplant™.
Revision African American Rhinoplasty – removal of Medpor Implant.
(Left) Pollybeak and over-projection caused by Medpor Implant. (Right) Revision Rhinoplasty – removal of Medpor Implant and replacement with custom carved silicone implant.
(Left) Revision Rhinoplasty Medpor Implant repairing width issue in middle third and naso-frontal angle causing excessive width of nasal bridge. (Right) Revision Rhinoplasty carved silicon implant.
Fig. 1 and 2 are before and after images of an African American – Ethnic Patient who had a Revision Rhinoplasty. Initially the patient had a Medpor Implant placed which caused a Pollybeak Deformity and, over-projection of the nasal-frontal angle (Fig. 1 – Profile View). The frontal view shows the Medpor Implant over-widening the middle third of the nose and the naso-frontal angle. Revision Rhinoplasty, by Dr. Slupchynskyj, removed the Medpor implant and replaced it with a custom carved silicone implant, SLUPimplant™ repairing the Pollybeak Deformity, over-projection of the naso-frontal angle and the width of the nasal bridge. Tissue deformities caused by Medpor Implant were irreversible in the reconstruction.
Other synthetic implants available to surgeons include meshed polymers such as Mersilene (Polyethylene terephthalate), Medpor, Gortex, metals and alloys, and Calcium Phosphate Cement.
Meshed polymers such as Mersilene (Polyethylene terephthalate) may promote extensive fibrous ingrowth. However, since they are not degradable following implantation, they pose a risk for infection. Medpor is a polyethylene implant, which is porous and allows the body to grow tissue into the implant. Surgeons using this implant will note that tissue in-growth helps keep the implant in place, however this can lead to complications rendering its removal very difficult. Once the implant is placed in the nose, the patient's tissue grows into the body of the implant within a few months. Should the implant get infected or should the patient want to change the implant for any reason, removal of the Medpor Implant is extremely challenging and could mean severely traumatizing the tissue in the implant and around it resulting in destroyed localized tissue and possible deformity. In fact, Medpor can become integrated into your nasal bone causing further difficulties in potential removal. Given the associated risks, Dr. Slupchynskyj does not use the Medpor implants on any of his patients, as removal of Medpor nasal implants is an arduous surgical task, which can potentially result in cosmetic malformation to the nasal bridge due to tissue in-growth. Despite any success of total removal, often reconstruction of the nasal bridge is necessary utilizing other implant(s). See what other surgeons have said about Medpor Nasal Implants.
With Dr. Slupchynskyj's 15 years of experience using customized silicone implants, there has been a very low complication rate–less than .01%. These findings are documented and published in the Archives of Facial Plastic Surgery" Journal. There was one case of infection where the implant had to be removed and was easily removed, as opposed to a Medpor Implant where removal would have entailed a major surgical procedure.
Gore-Tex (expanded polytetrafluoroethylene [ePTFE]) has also been used in primary and Revision Rhinoplasty to promote cellular attachment and tissue infiltration. An April 2011, retrospective study of 309 consecutive patients who underwent Rhinoplasty, including augmentation with Gore-Tex, during a 10-year period concludes that "Gore-Tex remains an effective implant material for nasal augmentation in Rhinoplasty." It is remarkable that it is "used only in situations where there is sufficient under and overlying soft-tissue coverage" for volume augmentation along the nasal dorsum and not for structural rigidity or support. However, there is a risk of infection, with up to 1.3% requiring implant removal in Primary Rhinoplasty increasing to 4.3% in revision cases. Gore-Tex is associated with an overall complication rate in all cases of 3.0% and an overall removal rate of 3.1%.
Gore-Tex is not adequate to build dorsal height. This implant is porous and comes in the form of sheets, which are required to be stacked on top of each other to create any volume or elevation in the nasal bridge. Since Gore-Tex is porous, there is tissue in-growth which raises the same potential complications as with the Medpor Implant. Conversely, the silicone implant is not porous, is one solid piece, is extremely versatile and offers superior structural support to the nose, and it can be removed if the patient so desires, without the attendant risks with a porous implant.
Removal of poorly placed, infected gortex graft.
Metals and Alloys: Titanium and Vitallium may facilitate osteointegration or direct bone adhesion and ingrowth in perforated implants. They are an alternative to Calvarial bone grafts in total nasal reconstruction.
Calcium Phosphate Cement: It may be appropriate for minor augmentation Rhinoplasty especially in an Asian patient, but long-term studies are still required.
A careful risk-benefit analysis of all the options above suggests that autogenous cartilage and bone are the primary choices for nasal implants in reconstructive surgery of the nose.
While e-PTFE implants are an effective substitute for the nasal dorsum, Autografts continue to be the choice for many Rhinoplasty surgeons.
SLUPimplant™ is indicated in Rhinoplasty Augmentation mostly in African American and ethnic patients to create a projected nasal frontal angle and raised dorsum, for instance, when the dorsum appears low or flat and the nasal frontal angle is depressed. To contour the tip of an African American nose characterized by a soft, round, and broad shape, Dr. Slupchynskyj removes soft tissue and fullness from the tip and add cartilage structure and uses "the patient's own cartilage from the outer ear to repair a defect in the septum of the nose or to create a new tip graft, or he can even use cartilage from to septum to create a tip graft".
Problem: Flat, depressed, low bridge and naso-frontal angle.
Low, depressed nasal frontal angle and bridge correction with custom carved SLUPimplant™.
(Left) low, depressed nasal frontal angle and bridge. (Right) Correction with custom carved SLUPimplant™.
Size of Implants: If implants are not of precise size and dimension, an oversized medpor or silastic implant can stretch and over-expand the nasal skin. Subsequently, any replacement of the implant with a smaller implant or more customized size and shape can raise challenges with the nasal skin unable to conform to the new shape. Therefore, a custom carved implant is crucial for great cosmetic results.
The following features are the key to successful nasal aumentation using silicone implants:
1. Custom carved silicone implant;
2. Precise pocket formation in the correct tissue plane of the nasal bridge;
3. Suturing the implant to the nasal bridge; and
4. Experience of the surgeon using silicone implant.
1. Wirth GA. Nasal Implants. Medscape e-Medicine. Jan 28, 2009.
http://emedicine.medscape.com/article/1282845-treatment#a1128. Accessed on June 28, 2011.
2. Godin MS, Waldman SR, Johnson CM Jr Nasal augmentation using Gore-Tex: a 10-year experience Arch Facial Plast Surg. 1999;1(2):118-122.
3. Wang TD. Gore-Tex Nasal Augmentation. Arch Facial Plast Surg. 2011;13(2):129-130. doi: 10.1001/archfacial.2011.10.
4. Kridel RW, Ashoori F, Liu ES, Hart CG.Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg. 2009 Nov-Dec;11(6):378-94.
5. Surgery of the African American Nose–Dorsal Angle Augmentation Using Custom Designed Silastic "S" Implant. Available at: http://africanamericanrhinoplasty.com/ethnic_rhinoplasty.htm. Accessed on June 29, 2011