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Nasal redux: HDPP sheet implants in secondary nasal reconstruction

Article-Nasal redux: HDPP sheet implants in secondary nasal reconstruction

Key iconKey Points

  • Autogenic materials are preferred in nasal dorsal augmentation, but when limitations are encountered, HDPP implants are a viable alternative

Dr. Copcu
Secondary rhinoplasty is considered to be one of the most challenging operations in cosmetic surgery. While autogenic materials are preferred in nasal dorsal augmentation, sometimes complications can arise such as donor site morbidity, restricted availability, difficulty shaping the graft, unpredictability of remodeling and resorption.

In secondary cases in which donor area limitations are encountered, Medpor Biomaterial (Porex Corporation, Newnan, Ga.) — high-density porous polyethylene (HDPP) implants can easily and effectively be used for nasal dorsal augmentation, experts tell Cosmetic Surgery Times . HDPP implants — inert, nonantigenic, nonabsorbable and easily applied, with pore sizes between 160 µm and 368 µm — allow for tissue in-growth and can be a very useful second choice in such cases.

Medpor Biomaterial sheets and blocks are readily trimmed with surgical scissors or a small scalpel blade. (Photo credit: Porex Surgical, Inc.)
"Generally, cosmetic surgeons believe that autogenous materials have more advantages than biomaterials," says Eray Copcu, M.D., associate professor and chief of the Department of Plastic, Reconstructive and Aesthetic Surgery, Adnan Menderes University, Aydin, Turkey. "But I prefer HDPP in the correction of deformities in secondary rhinoplasty, especially in a patients previously operated on with autogenous tissues." According to Dr. Copcu, alloplastic implants can be problematic, especially in the nasal region. The thin nasal skin may give rise to extrusion of the implant and the close proximity of the implant to the nasal mucosa and sebaceous glands may also lead to infection. For some practitioners, Medpor's firm but flexible characteristics make it suitable not only as dorsal onlay implants, but also as columellar struts and external valve battens.

"Sheet HDPP implants closely resemble the ideal alloplastic implant for facial augmentation and reconstruction, offering excellent host tissue tolerance, easy manipulability to produce the required shape, minimal recipient capsule formation, and demonstration of host tissue in-growth for stabilization," Dr. Copcu says.

Pre- (top) and post-operative view (bottom) of 32-year-old female patient who received a nasal dorsal HDPP implant for correction after having undergone three previous operations. (Photo credit: Eray Copcu, M.D.)
OPEN TECHNIQUE Dr. Copcu always uses the open rhinoplasty technique for the application of the implant in secondary rhinoplasty, as, in his opinion, it is superior to the closed technique. In his standard approach, Dr. Copcu proceeds with a transcolumellar, inverted V-incision. After extensive exposition of the nasal dorsum, remnants of the former operation and any cartilage or bone irregularities that have formed are removed. The nasal dorsum is then rasped and custom made HDPP blocks are sculpted using a No. 15 scalpel. The carved HDPP implants are subsequently inserted into the subperichondrial pocket and fixed to adjacent tissues with 6/0 prolene sutures.

Pre-operative (top) and post-operative (bottom) view of male patient who underwent secondary rhinoplasty using HDPP sheet implant material. (Photo credit: Eray Copcu, M.D.)
To help ensure a successful procedure, Dr. Copcu emphasizes that the surgeon be wary of two vital points: the thickness and quality of the tissue covering the implant and the appropriate shape and surface of the implant, ensuring that the implant is shaped correctly and is smoothed of any sharp edges.

"A sufficient pocket must be created," explains Dr. Copcu. "Meticulous dissection of the dorsal flap in open rhinoplasty should be done very carefully and extreme care must be taken when dissecting the flap. The thicker the flap, the less risk of complications."

REVISION EXCEPTION According to Anthony P. Sclafani, M.D., F.A.C.S., professor of otolaryngology at The New York Ear and Eye Infirmary in New York, "Autogenous cartilage, particularly septal and conchal, is preferable to any kind of implant. Grafts of autogenous cartilage carry lower risks, are readily available and the donor site morbidity is minimal. However, in revision cases," he explains, "these are frequently not available or are insufficient. So, for a scooped out nose, there might not be enough septal or conchal cartilage to build up an entire dorsum."

Historically, silicone was the most common implant material used. Although it can work well, it requires a healthy and preferably thicker skin-soft tissue envelope and is difficult to deploy in a manner which provides safe structural support. It is also more prone to infection because it is a solid implant and completely encapsulated.

If autogenous grafts are ruled out, Dr. Sclafani likes to use either HDPP, the older ePTFE (expanded polytetrafluoroethylene; W.L. Gore & Associates, Elkton, Md.), or a newer silicone implant that is enveloped in ePTFE (Implantech, Ventura, Calif.) because the porous ePTFE promotes soft tissue in-growth to stabilize the implant. He says these all can be used for dorsal augmentation, but only HDPP or silicone/ePTFE implants can be used to provide columellar support to increase tip projection.

PLACEMENT PARTICULARS In Dr. Sclafani's opinion, Medpor is a little more difficult to place surgically, not only because of its rigidity but also because of the coarseness of the implant, which makes it stick to tissues when deployed and does not slide as easily. However, he says, the Medpor implant can be used for dorsal augmentation, columellar support and nasal valve repair, since it has the same consistency as cartilage in terms of thickness and stiffness.

"Medpor is a more versatile material for plastic surgeons in the right setting," he notes. "It can work very well because its rigidity can offer good structural support. However, it's a little trickier to use in the sense that you need a more robust skin-soft tissue envelope."

Medpor is not the ideal implant choice for someone who has really thinned-out skin, Dr. Sclafani says, for example, from a previous surgery or if the patient simply has thin skin in general. "It's a little more problematic when you use it around the nasal tip if it isn't buried between the existing cartilage. If there's any pressure against the skin, it could erode through the skin," he cautions.

According to Dr. Sclafani, implants should not be used in patients with septal perforations, as chronic inflammation, infection and extrusion are common complications in these patients.

An infection of a porous implant will generally be seen within the first three months after surgery, he indicates. After three months, fibrous tissue has grown into the pores and completely sealed off the implant. Furthermore, there is very little micro-motion relative to the surrounding skin because of the soft tissue in-growth, as opposed to silicone in which the thin capsule around the implant allows motion and shifting. In Dr. Sclafani's experience, the infection rate with both the ePTFE and the Medpor implants is approximately one to two percent.

"I try to use cartilage whenever possible," he states. "If the patient doesn't have easily available cartilage and refuses rib, then I'll use either ePTFE or Medpor. If I need to do a simple dorsal augmentation, I'll use the ePTFE; however, if some structural support is needed, I'll use the Medpor."

According to Ilteris M. Emsen, M.D., Department of Plastic Reconstructive and Aesthetic Surgery, Numune State Hospital, Erzurum, Turkey, "Secondary rhinoplasties or crooked noses, either due to a previous rhinoplasty surgery or old trauma, can sometimes be challenging. Polyethylene material can be advantageous in those patients where an autogenous graft is contraindicated or [where you] simply do not want an autogenous graft done."

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