eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery
Nasal Implants
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.
Treatment
Surgical Therapy
Autologous materials
Autologous materials include cartilage, bone, and soft tissue.
Cartilage
Septal cartilage is the criterion standard material for nasal augmentation. It is quickly harvested in the same operative field and has no risk of disease transmission, rejection, or toxicity. However, prior surgery or trauma may preclude its use because of limited availability.
Another option is conchal cartilage. It leaves little or no cosmetic defect at the donor site. However, it may be brittle and difficult to sculpt. In addition, it may be insufficient when significant augmentation is needed, and it requires a separate operative site. The inherent curvature of conchal cartilage may increase the potential for postoperative warping.
Large amounts of donor cartilage can be provided by costal cartilage. Drawbacks include a chest scar, risk of pneumothorax, and possible warping of the graft.
Bone
Bone options include iliac crest and calvaria. Iliac crest provides flat bone for dorsal augmentation. However, it carries a significant risk of morbidity from its harvesting. In addition, embryologically it is endochondral bone and therefore may undergo resorption. Calvaria is the preferred bone for nasal augmentation. It has less postoperative morbidity and is closer to the operative field.
Because membranous bone undergoes less resorption, it is more suitable for use as a graft. The drawback is the possible risk of dural or cerebral injury from the harvesting. The risk of this complication is lessened with harvesting of the outer table only, leaving the inner table intact. Postoperative donor site morbidity can be lessened by saucerizing the defect edges and/or filling the defect with bone cements.
Soft tissue
Potential soft tissue implants include fascia and dermis. Both require a separate incision, and neither can provide large amounts of skeletal augmentation. In addition, neither provides structural support.
Alloplasts
Alloplasts for nasal augmentation include silicone rubber, expanded polytetrafluoroethylene (e-PTFE), and porous high-density polyethylene (PHDPE).
Silicone
Silicone rubber has been used for many years with varying reports of success. Although easy to place, extrusion rates of 24-55% have been reported. A thin fibrous capsule surrounds it with mild chronic foreign body reaction for the lifetime of the implant. It is poorly tolerated in thin-skinned areas and in revision cases. However, good results have been seen in Asian patients; this is possibly related to skin thickness.
Expanded polytetrafluoroethylene
E-PTFE is a microporous woven polymer comprised of fibrils of PTFE. The small pore size (22 mm) limits host tissue ingrowth to the periphery. It is usually well tolerated, with a less than 2% risk of infection, and it is found to be useful for volume enhancement of the nasal dorsum, glabella, and subnasale. However, it may not provide sufficient structural support in all cases.
Porous high-density polyethylene
PHDPE has internal pores of 100-250 mm that promote soft tissue and bony ingrowth, lending mechanical stability to the implant in its bed. (Image 2 shows a patient who underwent reconstruction with PHDPE.) PHDPE is provided in a number of shapes designed for the nose and other facial areas. It is easy to sculpt and can be molded by immersing it in hot water. Tissue ingrowth provides an avenue for cellular immune response, thereby imparting resistance and tolerance to exposure not seen with other alloplast implants. Disadvantages include its inability to be resterilized and the need for wide undermining because of its more rigid character.
Composite e-PTFE/silicone
Composite implants with a central solid silicone core coated with a thin layer of e-PTFE have become commercially available. Currently, these are available for either dorsal augmentation or combined columellar support and dorsal augmentation. Although these new implants are easy to use and may add additional qualities to e-PTFE implants (especially sufficient rigidity to increase tip support), long-term follow-up is needed to determine if the coating of e-PTFE is sufficient to eliminate the risk of implant extrusion.
Preoperative Details
A thorough preoperative discussion with the patient about the nature of the implant is mandatory. Patients are informed of their specific needs for surgery, and various autologous, homologous, and synthetic options are outlined. Patients are fully informed on the relative merits and risks of each material, and they must give an unrestricted informed consent prior to any procedure.
Intraoperative Details
Although some surgeons place alloplasts through an endonasal incision, the authors prefer an external rhinoplasty approach to avoid contamination of the implant with bacteria colonizing the nasal mucosa. The external approach also allows for exact suture placement when necessary.
Prior to placement, all implants are soaked in an antibiotic solution, and antibiotics are administered intravenously at the start of every surgery.
Postoperative Details
Oral antibiotics are administered postoperatively for 7-10 days, and patients are told to refrain from any activity (including tobacco use) that may reduce blood flow to the nose.
Complications
Although today's synthetic implants are more accepted and better studied than ever, some limitations must be considered.
Infection may occur by 2 distinct routes, direct inoculation (eg, placement of an implant through a contaminated area) and hematogenously. Infection occurs in 2-3% of patients with PHDPE and e-PTFE nasal implants and frequently requires early implant removal.
Extrusion of the implant is less likely following adequate tissue ingrowth into a porous implant but is more likely in solid rigid implants.
Shifting of the implant is also more likely in implants with limited fibrovascular ingrowth.
Outcome and Prognosis
Upon review of a group of 187 cases of functional and aesthetic nasal reconstruction using multiple PHDPE implants, only 6 implants were removed. One implant was removed, reduced in size, and reimplanted because of excessive augmentation. A second implant was removed 3 months postoperatively after the patient developed nasal cellulitis that did not respond to intravenous antibiotics. In a third patient with cocaine-induced septal perforation and saddle-nose deformity, removal of a dorsal implant was necessary following a blistering sunburn and subsequent infection. Three alar-batten implants were removed because of infection. The skin/soft tissue envelopes in these patients who developed cellulitis had been traumatized by ischemic changes from postoperative edema in an unpacked nose, heavy tobacco use, and/or multiple prior surgeries.
Reported results of silicone nasal implants vary widely and are clearly related to local factors, such as prior surgery, intercurrent vascular disease, or technique. Although some have reported successful use of silicone nasal implants, others have reported extrusion rates of 30% or higher, most notably when the implants were used for structural support in compromised skin/soft tissue envelopes. In contrast, expanded polytetrafluoroethylene (Gore-Tex) implants appear to be well tolerated in the nose. Conrad and Gillman reported a 97.3% long-term success rate with these implants.1
Longer-term follow-up is necessary to determine the actual success rate of these implants through the lifetime of the patient. Minimizing trauma and attention to sterile technique are essential to the success of any implant.
Future and Controversies
The technique of nasal reconstruction has undergone a slow transformation from simple skin coverage of gross midfacial tissue defects, to aesthetic contouring, and finally, to the dual goals of functional and aesthetic reconstruction.
Enough progress has been made in the understanding of implant physiology to facilitate a rational decision regarding implant use when adequate autologous tissue is unavailable. Although autogenous tissue is still by far the preferred material for nasal augmentation, it is no longer acceptable to maintain that alloplasts should never be used in the nose. Patients requiring significant amounts of augmentation, as well as those in whom sufficient autologous tissue of acceptable quality is unavailable, should be considered candidates for alloplast augmentation in the nose.
Further refinements in the form, texture, microstructure, and chemical composition of these implants will improve the short-term and long-term cosmetic and functional results of nasal reconstruction using alloplasts.
Multimedia
Media file 1: Preoperative lateral photograph of a patient with a saddle-nose deformity from trauma, with nasal obstruction.
Media file 2: Patient seen in Image 1, 2 years following nasal reconstruction with porous high-density polyethylene implants as a columellar strut and dorsal onlay.
References
Conrad K, Gillman G. A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Reconstr Surg. May 1998;101(6):1675-83; discussion 1684. [Medline].
Berghaus A, Stelter K. Alloplastic materials in rhinoplasty. Curr Opin Otolaryngol Head Neck Surg. Aug 2006;14(4):270-7. [Medline].
Costantino PD, Friedman CD, Lane A. Synthetic biomaterials in facial plastic and reconstructive surgery. Facial Plast Surg. Jan 1993;9(1):1-15. [Medline].
Davis PK, Jones SM. The complications of silastic implants. Experience with 137 consecutive cases. Br J Plast Surg. Oct 1971;24(4):405-11. [Medline].
Romo T 3rd, Sclafani AP, Sabini P. Use of porous high-density polyethylene in revision rhinoplasty and in the platyrrhine nose. Aesthetic Plast Surg. May-Jun 1998;22(3):211-21. [Medline].
Sclafani AP, Romo T. Alloplasts for nasal augmentation. In: Advances in Facial Implants. Vol 7. 1999.
Staffel G, Shockley W. Nasal implants. Otolaryngol Clin North Am. Apr 1995;28(2):295-308. [Medline].
Keywords
nasal implants, nasal implant, silicone nasal implant, nasal reconstruction, nasal restoration, nasal contour, nasal augmentation, nasal surgery, nose implants, saddle-nose deformity, rhinoplasty, nose job, alloplast, nasal deformity, nasal dorsum, poor nasal tip projection
Contributor Information and Disclosures
Author
Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Medicis None Speaking and teaching; Contura None Board membership; Contura Grant/research funds Independent contractor; Cascade Medical Grant/research funds Independent contractor; Cascade Medical None Board membership
Medical Editor
Gregory Branham, MD, Vice-Chair, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Saint Louis University School of Medicine
Gregory Branham, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, and Missouri State Medical Association
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center
Disclosure: Nothing to disclose.
CME Editor
Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown