eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Nasal Implants

Author: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Contributor Information and Disclosures

Updated: Nov 12, 2008

Introduction

Nasal reconstruction presents a significant challenge to the facial plastic surgeon. The dual goals of this endeavor are reestablishment of the desired aesthetic nasal contour and restoration of respiratory function.

Use of implantable materials, which vary from autologous materials such as septal cartilage) to synthetic implants such as expanded polytetrafluoroethylene (e-PTFE); Gore-Tex, WL Gore & Associates, Flagstaff, Ariz; and porous high-density polyethylene (PHDPE); Medpor, Porex Surgical, College Park, Ga) will be discussed.

History of the Procedure

Written description of nasal reconstruction dates from as early as 600 BC (Samhita Sushruta, India). Techniques of the Branca family (Sicily, AD 1440s) and the Vianeo family (Calabria, AD 1470s) were popularized and extended by Tagliacozzi's publication in Milan of De Curtorum Chirurgia per Insitionem (AD 1597). These techniques focused on soft tissue coverage of gross defects caused by battle injuries and penal nasal injuries.

By the late 19th and early 20th centuries, improvements in anesthesia techniques encouraged surgeons to perform procedures for subtler defects. Various materials were used for augmentation, including injected petroleum jelly or paraffin, gold, silver, aluminum, platinum, porcelain, celluloid, ivory, cork, stones from the Black Sea, fingernails, and a toothbrush handle.

Over the past 40 years, many other materials have reportedly been used for nasal augmentation. By far, the most common has been silicone rubber. However, the lack of incorporation of silicone into the surrounding tissues translates into significant drawbacks to its use, most notably a high potential for extrusion, inability to provide structural support, and lack of utility in thin-skinned areas; thus, the search for the ideal nasal implant still continues.

Problem

Structural nasal collapse or volume loss due to trauma (including prior surgery), autoimmune disease, neoplasm, or infection can lead to aesthetic deformity or nasal obstruction.

Etiology

The saddle-nose deformity is one of the more common deformities requiring major nasal augmentation. The most common etiologies of the saddle-nose deformity include the following:

• Trauma
• Prior nasal surgery
• Cocaine abuse

Less common etiologies include the following:

• Wegener granulomatosis
• Sarcoidosis
• Relapsing polychondritis
• Hansen disease (leprosy)

Presentation

The nose overresected during prior surgery typically demonstrates a scooped-out dorsum. Aggressive techniques at the nasal tip often lead to scarred lower lateral crura with a resultant pinched appearance. The loss of integrity of the tip cartilage also leads to nasal obstruction due to nasal valve collapse. Posttraumatic deformities are usually limited to poor projection of the nasal dorsum. Asian and African American patients demonstrate an acute nasolabial angle, a poorly defined and underprojected nasal tip, and a low dorsum.

Indications

• The most common site requiring augmentation in the nose is the dorsum. Previous surgery, trauma, and a congenitally low dorsum all require correction with dorsal augmentation.
• The incompetent nasal valve can cause nasal obstruction, and functional rehabilitation requires reconstruction with a semirigid implant.
• Volume augmentation is often required to increase an acute nasolabial angle.
• The overresected nose represents the stereotypical surgical nose. These patients commonly report nasal obstruction due to incompetent nasal valves. The tip may or may not be overrotated, and the dorsum is typically too low.
• Noses that experienced trauma most closely resemble the traditional saddle nose (see Image 1) and usually have a widened dorsum in addition to loss of dorsal height.

Relevant Anatomy

Two basic scenarios are commonly encountered in which augmentation is needed. A patient with a platyrrhine nose presents with a low wide dorsum, poor tip projection, and acute nasolabial angle. The overresected nose has a scooped-out dorsum, pinched tip, and incompetent nasal valves.

The platyrrhine nose may require nasal dorsal and tip augmentation, as well as a thin columnella strut and small particle premaxillary plumper implants. Overresected noses generally require reconstruction with bilateral, thin, curved nasal battens, as well as a short, thin columnella strut, small particle plumper implants, and a nasal dorsal implant without tip augmentation.

Of course, each nose is different, and the choice of specific techniques for individual patients depends on the specific problems encountered and the desired outcome of the patient. The external rhinoplasty approach is generally the procedure of choice when undertaking these types of nasal reconstruction.

Contraindications

Reconstruction with any material in the context of an autoimmune or infectious process is unlikely to yield satisfactory results. Likewise, patients who habitually use cocaine are advised to seek treatment of the addiction before any attempts at reconstruction. Prior surgery compromises the skin/soft tissue envelope, raising the likelihood of implant-related complications.

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