eMedicine Specialties > Plastic Surgery > Facial Augmentation

Nasal Implants

Author: Garrett A Wirth, MD, MS, FACS, Associate Clinical Professor of Plastic Surgery, Director of Research, Laboratory of Tissue Engineering and Regenerative Medicine, Aesthetic and Plastic Surgery Institute, University of California, Irvine; Medical Director, Long Beach Memorial Wound Healing Center
Coauthor(s): James G Hoehn, MD, Program Director, Professor, Department of Surgery, Division of Plastic Surgery, Albany Medical Center Hospital
Contributor Information and Disclosures

Updated: Jan 28, 2009

Introduction

The nose is critically involved in appearance, both to oneself and to others, and it is significantly involved in the perception of beauty both publicly and privately. Because of its central location on the face, plane of projection, and relatively weak chondrocutaneous support structure, the nose is susceptible to injury, and deformities are readily apparent.

Whatever the circumstances that led to the nasal deformity, the complex tasks of assessing the patient's nasal anatomy, pathologic defect, aesthetic qualities, baseline perception, planning the reconstruction, and preparing the patient for the possible positive and negative outcomes can be daunting. In planning for nasal reconstruction requiring an implant, careful decisions need to be made regarding the types of materials to substitute for support. Final soft-tissue coverage of the planned reconstruction is of paramount importance in the preparation.

History of the Procedure

In northern India, during the 6th century BC, Susruta focused on soft-tissue augmentation for amputation injuries and nasal reconstruction.1

Reproduction of plate from Susruta showing style ...

Reproduction of plate from Susruta showing style of nasal reconstruction. Note that support for the nasal bridge is absent. The intrinsic rigidity of the dermis was relied upon for structural support. (Susruta, An English Translation of the Susrita Samhita, based on original Sanskrit text. Edited and published by Kaniraj Kunjabal Blushagratna. Calcutta: Bose, 1916).

[ CLOSE WINDOW ]
Reproduction of plate from Susruta showing style ...

Reproduction of plate from Susruta showing style of nasal reconstruction. Note that support for the nasal bridge is absent. The intrinsic rigidity of the dermis was relied upon for structural support. (Susruta, An English Translation of the Susrita Samhita, based on original Sanskrit text. Edited and published by Kaniraj Kunjabal Blushagratna. Calcutta: Bose, 1916).


In the 16th and 17th centuries, Tagliocozzi used a tubed pedicle flap and Carpue, an Englishman, reinstituted the forehead flap.2,3

Reproduction of plate from Tagliocozzi as depicte...

Reproduction of plate from Tagliocozzi as depicted by Gnudi and Webster. Skin of the inner upper arm has minimal intrinsic rigidity and always requires internal structural support.

[ CLOSE WINDOW ]
Reproduction of plate from Tagliocozzi as depicte...

Reproduction of plate from Tagliocozzi as depicted by Gnudi and Webster. Skin of the inner upper arm has minimal intrinsic rigidity and always requires internal structural support.



Reproduction of plate from Carpue manuscript. Not...

Reproduction of plate from Carpue manuscript. Note refinements in flap design.

[ CLOSE WINDOW ]
Reproduction of plate from Carpue manuscript. Not...

Reproduction of plate from Carpue manuscript. Note refinements in flap design.


Various nonautogenous materials have been employed over the centuries to improve reconstruction of the nose by providing bridge support. Early attempts at finding the ideal or most suitable nasal implant for bridge construction included trials of materials such as paraffin, gold, silver, aluminum, ivory, cork, stones from the Black Sea, polyethylene, rubber, silicone, lead, and a toothbrush handle.

Currently, general categories of available materials include autografts, homografts, and allografts. This article covers the variety of materials commonly employed. The pros and cons of various materials are detailed and illustrated.

Problem

The choice of nasal implants to be placed in reconstructive surgery of the nose is a difficult but important component in the patient's care. The degree of loss noted in tip support, bridge contour, or nasal valve collapse may mandate implant use in nasal reconstruction. Each of the various materials has benefits and pitfalls, which must be balanced against the surgeon's familiarity with each material. Because of the nose's central location, minor defects of reconstruction may be particularly noticeable to any casual observer but may play a much larger role psychologically in the patient's perception of self. Based on the authors' review of the literature and clinical experience, autogenous cartilage and/or bone are recommended as the primary choices for nasal implants.

Indications

Although the major underlying cause of nasal reconstruction is trauma, a number of pathologic entities traditionally have required surgical nasal reconstruction (eg, congenital malformations, malignant destruction, septal perforations, granulomatous disease, congenital syphilis, leishmaniasis, leprosy). Whatever the cause of the defect, nasal reconstruction with or without various implant materials allows restoration of function along with restoration of an aesthetically critical component of the face.

Relevant Anatomy

A prerequisite to nasal reconstruction is familiarity with nasal anatomy and proportions. The nose is generally divided by anatomic units into thirds. The upper third of the nose, or bony vault, is represented by the paired nasal bones that overlie the nasal spine of the frontal bone. The cartilaginous vault represents the lower two thirds of the nose, with the middle third being the region of the upper lateral cartilages, and the lower third involving the nasal tip, septum, and lower lateral (alar) cartilages. The general function of the nose is to warm and humidify incoming air. To achieve both form and function, the nasal vestibule should comprise approximately one half to two thirds of the nasal lobule as viewed from the basal projection. Attention should be dedicated to reconstructing the columella, tip, and ala to form an adequate nostril internally while incorporating aesthetics externally.

Contraindications

Ongoing infection or conditions requiring further therapy (eg, serial débridements) are examples of contraindications to reconstruction. Address patient stabilization and optimization, including nutritional status when possible, prior to surgical intervention. Therapies such as radiation or chemotherapy should be completed prior to reconstruction.

More on Nasal Implants

Overview: Nasal Implants
Workup: Nasal Implants
Treatment: Nasal Implants
Follow-up: Nasal Implants
Multimedia: Nasal Implants
References
[ CLOSE WINDOW ]

References

  1. Susruta AN. Kaniraj Kunjabal Blushagratna, ed. English translation of the Susrita Samhita, based on original Sanskrit text. Calcutta: Kaniraj Kunjabal Blushagratna; 1916.

  2. Gnudi MT, Webster JP. The life and lives of Gaspar Tagliacozzi. Los Angeles: Zeitlin & Ver Brugge; 1976.

  3. Carpue JC. An account of two successful operations for restoring a host nose. In: The Classics of Medicine Library. Birmingham: 1981.

  4. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg. Oct 1997;13(4):279-90. [Medline].

  5. Sheen JH. Secondary rhinoplasty. In: McCarthy JG, ed. Plastic Surgery: The Face, Part II. Vol 3. Philadelphia, Pa: WB Saunders Co; 1990:1895-923.

  6. Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg. May 1981;67(5):597-605. [Medline].

  7. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg. May 2000;105(6):2229-41; discussion 2242-3. [Medline].

  8. Guerrerosantos J. Temporoparietal free fascia grafts in rhinoplasty. Plast Reconstr Surg. Oct 1984;74(4):465-75. [Medline].

  9. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg. Jun 2004;113(7):2156-71. [Medline].

  10. Erol OO, Gundogan H. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg. Sep 15 2005;116(4):1169-71; author reply 1171-3. [Medline].

  11. Daniel RK. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg (Letters and Viewpoints). Sept 2005;116(4):1171-3.

  12. Brenner KA, McConnell MP, Evans GR. Survival of diced cartilage grafts: an experimental study. Plast Reconstr Surg. Jan 2006;117(1):105-15. [Medline].

  13. Britt JC, Park SS. Autogenous tissue-engineered cartilage: evaluation as an implant material. Arch Otolaryngol Head Neck Surg. Jun 1998;124(6):671-7. [Medline].

  14. Romo T, Jablonski RD. Nasal reconstruction using split calvarial grafts. Otolaryngol Head Neck Surg. Nov 1992;107(5):622-30. [Medline].

  15. Carter WW. Transplantation of bone for the correction of depressed deformities of the nose, with report of cases. Laryngoscope. 1911;21:94-97.

  16. Macomber DW. Cancellous iliac bone in depression of forehead, nose and chin. Plast Reconstr Surg. 1949;4:157-162.

  17. Zins JE, Whitaker LA. Membranous versus endochondral bone: implications for craniofacial reconstruction. Plast Reconstr Surg. Dec 1983;72(6):778-85. [Medline].

  18. Powell NB, Riley RW. Facial contouring with outer-table calvarial bone. A 4-year experience. Arch Otolaryngol Head Neck Surg. Dec 1989;115(12):1454-8. [Medline].

  19. Celik M, Haliloglu T, Baycin N. Bone chips and diced cartilage: an anatomically adopted graft for the nasal dorsum. Aesthetic Plast Surg. Jan-Feb 2004;28(1):8-12. [Medline].

  20. Miller TA. Temporalis fascia grafts for facial and nasal contour augmentation. Plast Reconstr Surg. Apr 1988;81(4):524-33. [Medline].

  21. Kridel RW, Konior RJ. Irradiated cartilage grafts in the nose. A preliminary report. Arch Otolaryngol Head Neck Surg. Jan 1993;119(1):24-30; discussion 30-1. [Medline].

  22. Welling DB, Maves MD, Schuller DE, Bardach J. Irradiated homologous cartilage grafts. Long-term results. Arch Otolaryngol Head Neck Surg. Mar 1988;114(3):291-5. [Medline].

  23. Demirkan F, Arslan E, Unal S. Irradiated homologous costal cartilage: versatile grafting material for rhinoplasty. Aesthetic Plast Surg. May-Jun 2003;27(3):213-20. [Medline].

  24. Burke AJ, Wang TD, Cook TA. Irradiated homograft rib cartilage in facial reconstruction. Arch Facial Plast Surg. Sep-Oct 2004;6(5):334-41. [Medline].

  25. Strauch B, Wallach SG. Reconstruction with irradiated homograft costal cartilage. Plast Reconstr Surg. Jun 2003;111(7):2405-11; discussion 2412-3. [Medline].

  26. Ayshford CA, Shykhon M, Uppal HS, Wake, M. Endoscopic repair of nasal septal perforation with acellular human dermal allograft and an inferior turbinate flap. Clin Otolaryngol Allied Sci. Feb 2003;28(1):29-33. [Medline].

  27. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of alloderm for the correction of nasal contour deformities. Plast Reconstr Surg. Feb 2001;107(2):561-70; discussion 571. [Medline].

  28. Gryskiewicz JM. Waste not, want not: the use of AlloDerm in secondary rhinoplasty. Plast Reconstr Surg. Dec 2005;116(7):1999-2004. [Medline].

  29. Jackson IT, Yavuzer R. AlloDerm for dorsal nasal irregularities. Plast Reconstr Surg. Feb 2001;107(2):553-8; discussion 559-60. [Medline].

  30. Saray A. Porcine dermal collagen (Permacol) for facial contour augmentation: preliminary report. Aesthetic Plast Surg. Sep-Oct 2003;27(5):368-75. [Medline].

  31. Colton JJ, Beekhuis GJ. Use of Mersilene mesh in nasal augmentation. Facial Plast Surg. Jul 1992;8(3):149-56. [Medline].

  32. Sclafani AP, Thomas JR, Cox AJ, Cooper MH. Clinical and histologic response of subcutaneous expanded polytetrafluoroethylene (Gore-Tex) and porous high-density polyethylene (Medpor) implants to acute and early infection. Arch Otolaryngol Head Neck Surg. Mar 1997;123(3):328-36. [Medline].

  33. Niechajev I. Porous polyethylene implants for nasal reconstruction: clinical and histologic studies. Aesthetic Plast Surg. Nov-Dec 1999;23(6):395-402. [Medline].

  34. Romo T, Choe KS, Sclafani AP. Cleft lip nasal reconstruction using porous high-density polyethylene. Arch Facial Plast Surg. Mar-Apr 2003;5(2):175-9. [Medline].

  35. Romo T, Choe KS, Sclafani AP. Secondary cleft-lip rhinoplasty utilizing porous high-density polyethylene. Facial Plast Surg. Nov 2003;19(4):369-77. [Medline].

  36. Romo T, Litner JA, Sclafani AP. Management of the severe bulbous nasal tip using porous polyethylene alloimplants. Facial Plast Surg. Nov 2003;19(4):341-8. [Medline].

  37. Ham J, Miller PJ. Expanded polytetrafluoroethylene implants in rhinoplasty: literature review, operative techniques, and outcome. Facial Plast Surg. Nov 2003;19(4):331-9. [Medline].

  38. Jin HR, Lee JY, Yeon JY, Rhee CS. A multicenter evaluation of the safety of Gore-Tex as an implant in Asian rhinoplasty. Am J Rhinol. Nov-Dec 2006;20(6):615-9. [Medline].

  39. Maas CS, Gnepp DR, Bumpous J. Expanded polytetrafluoroethylene (Gore-Tex soft-tissue patch) in facial augmentation. Arch Otolaryngol Head Neck Surg. Sep 1993;119(9):1008-14. [Medline].

  40. Inanli S, Sari M, Baylancicek S. The use of expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty. Aesthetic Plast Surg. Jul-Aug 2007;31(4):345-8. [Medline].

  41. Godin MS, Waldman SR, Johnson CM. The use of expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty. A 6-year experience. Arch Otolaryngol Head Neck Surg. Oct 1995;121(10):1131-6. [Medline].

  42. Zeng YJ, Sun XP, Yang J, et al. Mechanical properties of nasal fascia and periosteum. Clin Biomech (Bristol, Avon). Oct 2003;18(8):760-4. [Medline].

  43. Deva AK, Merten S, Chang L. Silicone in nasal augmentation rhinoplasty: a decade of clinical experience. Plast Reconstr Surg. Sep 1998;102(4):1230-7. [Medline].

  44. Bikhazi NB, Chow AW, Maas CS. Nasal reconstruction using a combination of alloplastic materials and autogenous tissues: a surgical alternative. Laryngoscope. Aug 1997;107(8):1086-93. [Medline].

  45. Okada E, Maruyama Y, Hayashi A. Nasal augmentation using calcium phosphate cement. J Craniofac Surg. Jan 2004;15(1):102-5. [Medline].

  46. Beekhuis GJ. Saddle nose deformity: etiology, prevention, and treatment; augmentation rhinoplasty with polyamide. Laryngoscope. Jan 1974;84(1):2-42. [Medline].

  47. Brent B. The versatile cartilage autograft: current trends in clinical transplantation. Clin Plast Surg. Apr 1979;6(2):163-80. [Medline].

  48. Brown BL, Neel HB, Kern EB. Implants of Supramid, Proplast, Plasti-Pore, and Silastic. Arch Otolaryngol. Oct 1979;105(10):605-9. [Medline].

  49. Bujia J. Determination of the viability of crushed cartilage grafts: clinical implications for wound healing in nasal surgery. Ann Plast Surg. Mar 1994;32(3):261-5. [Medline].

  50. Daniel RK. Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg. Oct 1994;94(5):597-609; discussion 610-1. [Medline].

  51. Elahi MM, Jackson IT, Moreira-Gonzalez A, Yamini, D. Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases. Plast Reconstr Surg. Mar 2003;111(3):1309-18; discussion 1319-21. [Medline].

  52. Frodel JL, Marentette LJ, Quatela VC, Weinstein GS. Calvarial bone graft harvest. Techniques, considerations, and morbidity. Arch Otolaryngol Head Neck Surg. Jan 1993;119(1):17-23. [Medline].

  53. Kline RM, Wolfe SA. Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg. Jan 1995;95(1):5-13; discussion 14-20. [Medline].

  54. Kridel RW, Kraus WM. Grafts and implants in revision rhinoplasty. Facial Plast Surg Clin North Am. 1995;3:473-86.

  55. Lawson W, Reino AJ, Seidman D. The silicone columellar strut. Plast Reconstr Surg. Apr 1996;97(5):938-43. [Medline].

  56. Lindsey WH, Ogle RC, Morgan RF, et al. Nasal reconstruction using an osteoconductive collagen gel matrix. Arch Otolaryngol Head Neck Surg. Jan 1996;122(1):37-40. [Medline].

  57. McDowell F, Valone JA, Brown JB. Bibliography and historical note on plastic surgery of the nose. Plast Reconstr Surg. 1952;10:149-86.

  58. Silver WE, Goldberg J. Nasal grafts and implants. Facial Plast Surg Clin North Am. 1994;2:477-99.

  59. Stucker FJ. Auto-Alloplast: a contemporary concept in facial implantation. Facial Plast Surg. 1986;3:137-9.

  60. Tardy ME, Denneny J, Fritsch MH. The versatile cartilage autograft in reconstruction of the nose and face. Laryngoscope. May 1985;95(5):523-33. [Medline].

  61. Taylor IT, Yavuzer R. Alloderm for dorsal nasal irregularities. Plast Reconstr Surg. 2001;107(2):553-8.

  62. Tholpady SS, Schlosser R, Spotnitz W, et al. Repair of an osseous facial critical-size defect using augmented fibrin sealant. Laryngoscope. Oct 1999;109(10):1585-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

nasal implant, nasal implants, nose implants, nose deformities, nasal deformities, nasal reconstruction, nasal surgery, nose surgery, nose reconstruction

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Garrett A Wirth, MD, MS, FACS, Associate Clinical Professor of Plastic Surgery, Director of Research, Laboratory of Tissue Engineering and Regenerative Medicine, Aesthetic and Plastic Surgery Institute, University of California, Irvine; Medical Director, Long Beach Memorial Wound Healing Center
Garrett A Wirth, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Society of Plastic Surgeons, Association for Academic Surgery, and Plastic Surgery Research Council
Disclosure: Nothing to disclose.

Coauthor(s)

James G Hoehn, MD, Program Director, Professor, Department of Surgery, Division of Plastic Surgery, Albany Medical Center Hospital
James G Hoehn, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Medical Editor

Gregory Caputy, MD, PhD, Chief, Department of Plastic Surgery, Aesthetica Plastic and Laser Surgery Center of Honolulu
Gregory Caputy, MD, PhD is a member of the following medical societies: American Medical Association, American Society for Laser Medicine and Surgery, Canadian Medical Association, Hawaii Medical Association, International College of Surgeons, International College of Surgeons US Section, Pan-Pacific Surgical Association, and Wound Healing Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Edward Owen Terino, MD, Director, Department of Plastic Surgery, Los Robles Medical Center
Edward Owen Terino, MD is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, and International College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.