Literature Experience

GRAFTS

In the most recent comprehensive treatment of the subject of grafts and implants in rhinoplasty, Maas et al.1 state that "autograft cartilage is the most commonly used material in rhino-plasty and remains the standard against which all others are compared." There is no disagreement with this statement among experts. When used to augment or support the nose, autogenous cartilage has proved to provide long-lasting clinical correction and to be very resistant to infection or extrusion.2 Tardy3 reports more than 6000 cartilage autografts implanted over 25 years, with no incidence of rejection or infection: "infrequent complications ... have stemmed from technical errors that diminish with experience ... . No significant complications have occurred from the inherent unique properties of the cartilage autograft itself." The issue of the technical errors is

TABLE 33-1

Materials for Nasal Reconstruction

Grafts (autologous unless specified otherwise) Cartilage Septal Other nasal Ear Rib Autologous Homologous Heterologous Bone

Calvarium Rib

Iliac crest Dermis Autologous Homologous, acellular Fat

Fascia periosteum Collagen Implants Silastic Silicone Mersilene Supramid Gore-Tex Proplast an important one. Sheen and Tardy spend considerable space discussing technical considerations to ensure adequate blood supply, and avoidance of malposition and visibility, the two most common problems with autografts. I shall return to this issue later.

IMPLANTS

The medical literature is replete with articles advancing the use of one or another kind of new implant material. As time goes on, new implants continue to be advanced, which would suggest that no one has been entirely happy with the materials that were previously advanced. Unfortunately, the failures are not published with the same timeliness as are the initial successes.

Typically, articles that tout the use of one or another implant report complication rates of less than 5%.4-6 Reports of complications often come from other investigators, citing their own experience with implants inserted by other surgeons. I especially like the wording of a Chinese article that analyzes 349 complications (how much is enough?) of dorsal augmentation using ersatz materials.7 Tardy says it very well: "The continuing opportunity to care for referred patients suffering from the unpleasant results of nasal implant rejection influences significantly a philosophy of conservatism and patient safety above all else."

Things change pretty quickly on the nasal implant scene. A comparison of two excellent review articles published only 10 years apart points this up very well. A well researched review article in 1987 by Adams8 can be compared with similarly scholarly reviews by Kridel and Kraus9 and Maas et al.1 in 1995 and 1997, respectively. Table 33-2 divides the critiques of these materials into two categories: Then and Now.

Although little, if any, harm has been done by properly performed liquid silicone injections, much legal hay has been made of this substance. Is there an alloplast that is immune from sud-

TABLE 33-2

Nasal Implants: Then and Now

Implant Material Thena

Supramid

Mersilene Was not yet on the radar screen

Proplast "Has found it very useful for augmentation of the nasal dorsum and nasal tip support."

Silicone fluid "A very safe product that gives excellent results____Highly versatile."

denly being declared illegal at some point in time, putting both the manufacturer and the practitioner at great risk?

What about the fact that we continue to use Silastic implants in the nose, even though it is well documented that "in nasal augmentation its use is limited. Thin soft tissue coverage, constant movement of the nose, and frequent midface trauma lead to an unacceptably large incidence of dislodgment and extrusion."8

0 0

Post a comment