The Future Conclusion

Autologous, homologous, and alloplastic implants all possess inherent strengths and weaknesses. Tissue-engineered autografts could potentially overcome the biocompatibility issues of alloplasts and the donor site morbidity and limited supply issues associated with autografts. Vacanti et al.72'73 pioneered the development of xenograft tissue-engineered bovine cartilage grafts placed in immune-depleted mice. More recently, work has been done using autologous bioengineered cartilage grafts in rabbits.74 Rabbit chondrocytes were harvested and grown in vitro for 5 days, followed by placement on polyglycolic acid nonwoven felt combined with poly-L-lactic acid. This porous, pre-shaped scaffold allowed for directed chondrocyte development into cartilage. Britt and Park demonstrated impressive short-term (4 to 8 weeks) and long-term (6 to 12 months) results using these tissue engineered implants placed into the flank of the donor rabbits. Relatively large amounts of host specific cartilage could be produced in this manner, which would have a significant impact on implantation protocols in the future. Cartilage harvested in

Loss of nasal structure and support often mandates the need for implant materials to improve both form and function of the nose. Autologous implants, most notably septal cartilage, are the nasal grafts to which all others should be compared. Other autologous materials, such as auricular cartilage, costal cartilage, calverial bone, fascia, perichondrium, and dermis, are excellent materials for implantation in the nose. Irradiated rib and acellular dermis are homologous alternatives and should be considered in patients who cannot tolerate the additional morbidity associated with graft harvesting or who do not possess enough autologous material. Although alloplastic implants are plentiful and easy to shape and provide a natural contour under the skin, these materials have the heightened potential for complications and are therefore the least desirable materials to be used as a nasal graft. Their placement should be limited to the relatively immobile nasal dor-sum or premaxilla, and the patient should be thoroughly counseled as to the risk of infection or extrusion with these materials. In the not too distant future, bioengineered cartilage may become another option for nasal procedures requiring graft material.

Mingrone et al.—CHAPTER 31

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Alloplastic or Homograft Implantation for Nasal Reconstruction

William H. Beeson

CHAPTER 32

The use of implants in rhinoplasty is controversial. A variety of materials are commonly employed in nasal surgery for augmentation and for reconstruction. Autogenous tissue has long been advocated as the mainstay for nasal implants. Autogenous cartilage is most commonly employed for structural and augmentation grafting in the nasal tip, as well as for dorsal deformities. However, the limited availability and unpredictable resorption of both autologous and homologous implants have made newer alloplastic implants important considerations for dorsal augmentation.

Selecting the most suitable graft or implant material for soft tissue augmentation is difficult. A wide variety of materials and techniques are employed by outstanding surgeons who have equally compelling arguments for the materials they use. No single material is suitable for all augmentation and nasal reconstruction situations. Each has its advantages and disadvantages (Table 32-1). The surgeon's own experience and personal preference play a large role in the success of the material used.

The indications for soft tissue augmentation in the nose are most commonly associated with depression over the cartilaginous or bony dorsum pyramid—the so-called saddle-nose deformity. This can occur to a variety of degrees and as the result of a variety of causes. This deformity can result from congenital abnormalities such as aplasia of the nasal bones. It can be secondary to trauma, which can produce septal hematoma and cartilaginous necrosis or disarticulation of the upper lateral cartilages and resulting in dorsal depression. It can also be the result of atrogenic causes, such as overresection of the quadrangular cartilage in septoplasty surgery. Studies have shown that 39% of patients undergoing extensive septal reconstructive surgery independent of rhinoplasty surgery exhibited some degree of external deformity with time. Cartilaginous saddle-nose deformity in the middle one-third of the nose is frequently the consequence of radical septal surgery.

In a review of 153 revision rhinoplasties, Stucker1 noted that 58 patients presented with defects in the bony dorsum and

TABLE 32-1

Summary of Augmentation Materials and Uses

Material Advantages Disadvantages Nose

TABLE 32-1

Summary of Augmentation Materials and Uses

Material Advantages Disadvantages Nose

Bone

Becomes living part Does not warp

Requires precise placement Second surgical site

+

Cartilage

Minimal resorption Minimal displacement Minimal extrusion

Limited quantity available Auricular cartilage may be difficult to contour Rib cartilage warps

++++

Dermis and fat

Minimal extrusion

Significant resorption

0

Zyderm

Injectable

Significant resorption

+

Purified acellular human dermal graft

Readily available Easily sculpted

Possible resorption Long-term effects unknown

++

Silastic

Easily sculpted Low tissue reactivity

Extrusion with superficial placement

+

Mersilene

Facilitates tissue ingrowth Well tolerated by tissues

Soft, potential tissue reactivity

+++

e-PTFE

Readily available Easily contoured Provides for some tissue ingrowth for stabilization

Potential extrusion

++++

91 presented with defects of the cartilaginous vault. Approximately 20% of the defects would be classified as saddle-nose deformities requiring some degree of augmentation. Thus, augmentation of the bony or cartilaginous dorsum is not an infrequent consequence of rhinoplasty surgery.

0 0

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