Alloplastic materials in rhinoplasty

Subcutaneously Transplanted Fresh Cartilage in Allogeneic and Xenogeneic Immunocompetent Mouse

Cartilage is considered to be immune privileged in general. Clinically, live cells are removed from subcutaneously transplanted allogeneic cartilage mainly for preservation and for infection control. However, because maintaining cartilage feature requires live chondrocyte, it would be beneficial to subcutaneously transplant cartilage with live chondrocyte even if it was allogeneic. We harvested femoral head from 3-week-old male C57BL/6 mice, subcutaneously transplanted to 6-week-old male mice, BALB/c, BALB/c nu/nu, or C57BL/6-Tg (enhanced green fluorescent protein [EGFP] under the control of the CMV-IE enhancer, chicken beta-actin promoter, rabbit beta-globin genomic DNA [CAG promoter]), as allogeneic, allogeneic immunodeficient control, or syngeneic transplantation. We also transplanted cartilaginous particles from human induced pluripotent stem cells derived from human leukocyte antigen homozygous donor to 6-week-old male mice either BALB/c and BALB/c nu/nu as xenogeneic or xenogeneic immunodeficient control. The transplantation periods were 1, 2, 3, 4, 8, 12, and 24 weeks. As the result, we did not observe exposure of the transplant or apparent macroscopic inflammatory in all samples. Histological analysis suggested that the femoral head showed focal ossification and thinning in syngeneic transplantation. In allogeneic transplantation, slight invasion of CD3 (+) T cell and the denaturation of the cartilage were observed, suggesting immune reaction against allogeneic cartilage. In xenogeneic transplantation, slight invasion of CD3 (+) cell and CD4 (+) cell and the structure of the perichondrium-like tissue got unclear, suggesting slight immune reaction against xenogeneic cartilage. Our findings suggest that we should carefully investigate for appropriate procedure to control immune reaction against allogeneic cartilage with live chondrocyte and to maintain its cartilage feature for long time.

The Use of Acellular Human Dermis as a Dorsal Camouflaging Graft in Rhinoplasty

Background: Acellular human dermis (AHD) has many uses in rhinoplasty, but its long-term use as a camouflaging graft has not been adequately described. Objective: To measure the long-term outcomes (infections/contour irregularities) of AHD used as a camouflage graft in rhinoplasty. Methods: A retrospective study of 91 patients who underwent rhinoplasty requiring AHD as a camouflage graft for a 20-year time period (2000-2020) was performed. Complications, revisions, and long-term outcomes were assessed. Surgical technique for AHD use as a dorsal and tip camouflage graft was described in detail and illustrated using intraoperative photography. Results: Of the 91 patients who required AHD in their rhinoplasties, 70 (77%) were performed in revision cases to thicken thinned and scarred skin envelopes. Only 1% had postoperative contour problems that were attributable to AHD, and only 3% had resorption of the AHD. Four percent had postoperative infections, all of which resolved with a single course of oral antibiotics. Patients were followed a mean of 3.8 years. Conclusions: AHD can be a safe, effective, and readily available option for use in thickening the nasal skin envelope in rhinoplasty.

Complications of Diced Cartilage Wrapped in Blood Products in Rhinoplasty: A Meta-Analysis

BACKGROUND

Diced cartilage wrapped in blood products has been increasingly advocated in rhinoplasty. The complication is a major concern of the procedure. This meta-analysis aims to assess the complication rates and revision rate of this procedure.

METHODS

All original articles published up to March 2022 were searched through PubMed, Embase, and Web of Science databases. Additional articles were added through reference searching. Articles were included for meta-analysis according to inclusion criteria. Data were extracted by 2 individuals independently and the analysis was conducted through Stata 12.0 software (StataCorp., College Station, Texas).

RESULTS

A total of 559 articles were initially found and an additional 1 article was added through reference searching. A total of 11 articles including 469 patients were included for meta-analysis. The results indicated that the total complication rates were 1.2% for irregularity, 0.2% for visibility, 0.7% for deviation, 1% for erythema, and 0% for graft resorption, depression, and infection. The revision rate was 1.2%.

CONCLUSIONS

The overall complication and revision rates of diced cartilage wrapped in blood products in rhinoplasty were relatively low. Considering the limited number of related studies, a larger sample size, long-term follow-up, clear diagnostic criteria, and detailed methods of measurement are expected in further research.

Surface Modification of Porous Polyethylene Implants with an Albumin-Based Nanocarrier-Release System

BACKGROUND

Porous polyethylene (PPE) implants are used for the reconstruction of tissue defects but have a risk of rejection in case of insufficient ingrowth into the host tissue. Various growth factors can promote implant ingrowth, yet a long-term gradient is a prerequisite for the mediation of these effects. As modification of the implant surface with nanocarriers may facilitate a long-term gradient by sustained factor release, implants modified with crosslinked albumin nanocarriers were evaluated in vivo.

METHODS

Nanocarriers from murine serum albumin (MSA) were prepared by an inverse miniemulsion technique encapsulating either a low- or high-molar mass fluorescent cargo. PPE implants were subsequently coated with these nanocarriers. In control cohorts, the implant was coated with the homologue non-encapsulated cargo substance by dip coating. Implants were consequently analyzed in vivo using repetitive fluorescence microscopy utilizing the dorsal skinfold chamber in mice for ten days post implantation.

RESULTS

Implant-modification with MSA nanocarriers significantly prolonged the presence of the encapsulated small molecules while macromolecules were detectable during the investigated timeframe regardless of the form of application.

CONCLUSIONS

Surface modification of PPE implants with MSA nanocarriers results in the alternation of release kinetics especially when small molecular substances are used and therefore allows a prolonged factor release for the promotion of implant integration.

Tubed Temporalis Fascia for Nasal Dorsal Contouring: A Novel Technique

INTRODUCTION

Nasal dorsum irregularities may occur after nasal trauma or as a postrhinoplasty complication. Here, we present a novel technique using temporalis fascia (TF) grafting for primary and revision rhinoplasty to repair the nasal dorsum, hide nasal irregularities, and improve nasal contouring.

METHODS

This prospective cohort study was conducted from January 2019 to June 2019 and evaluated nasal dorsal contouring using the TF in a tubed form. The outcome variables were patient satisfaction, dorsal irregularity, and contour definition. The predictor variable was the use of tubed TF for dorsal augmentation. Other associated variables were age, sex, indication for surgery, surgery type, and graft size. Patient satisfaction was evaluated using the Rhinoplasty Outcome Evaluation questionnaire. A rhinoplasty specialist other than the surgeon who performed the procedure evaluated the dorsal augmentation outcomes by inspection and palpation of the dorsum. All statistical analyses were performed using the SPSS software.

RESULTS

Seventy-four patients (21.6% men and 78.4% women) were treated with the tubed TF. The mean age was 28.97 years. Thin skin was the most common indication (48.6%) for using TF. The graft size was 2-5 cm; inspection and palpation revealed no irregularities. No reception site complications occurred. One patient had a mild hematoma at the donor site. The mean patient satisfaction score was 10.14 preoperatively and 19.95 postoperatively (p = 0.001).

DISCUSSION/CONCLUSIONS

Our novel technique of using the TF graft in a tubed form was easy to perform. Furthermore, the tubed TF covers all irregularities, is good for dorsal augmentation, and improves dorsal contouring and definition.

Will Tissue-Engineering Strategies Bring New Hope for the Reconstruction of Nasal Septal Cartilage?

The nasal septal cartilage plays an important role in the growth of midface and as a vertical strut preventing the collapse of the nasal bones. The repair of nasal cartilage defects remains a major challenge in reconstructive surgery. The tissue engineering strategy in the development of tissue has opened a new perspective to generate functional tissue for transplantation. Given the poor regenerative properties of cartilage and a limited amount of autologous cartilage availability, intense interest has evoked for tissue engineering approaches for cartilage development to provide better outcomes for patients who require nasal septal reconstruction. Despite numerous attempts to substitute the shapely hyaline cartilage in the nasal cartilages, many significant challenges remained unanswered. The aim of this research was to carry out a critical review of the literature on research work carried out on the development of septal cartilage using a tissue engineering approach, concerning different cell sources, scaffolds and growth factors, as well as its clinical pathway and trials have already been carried out.

The Use of Expanded Polytetrafluoroethylene in Short Nose Elongation: Fourteen Years of Clinical Experience

BACKGROUND

Short nose elongation is a relatively common rhinoplasty procedure, especially in Asia. The selection of the adequate graft material is challenging. Previous reports have described the application of expanded polytetrafluoroethylene (ePTFE) for dorsal augmentation rhinoplasty, but studies using ePTFE for nose elongation are lacking. We propose ePTFE as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 14-year experience.

METHODS

From February 2003 to December 2016, 206 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using an ePTFE implant. Nasal lengths before and after surgery were measured using a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey.

RESULTS

Nasal elongation was successfully achieved using ePTFE. Mean increase in nasal length was 4.36 ± 0.85 mm. The mean follow-up period was 13.3 months, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 6.8%. Complications included infection, implant extrusion, migration, deviation, visibility, and/or prominence, tissue reaction, and reddening of the nasal skin. Most patients (93.6%) rated their outcome as improved and much improved.

CONCLUSIONS

Nasal elongation using ePTFE implantation is a feasible therapeutic approach for patients with short noses. Reliable outcomes and the absence of donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Use of a fibrinogen-thrombin sponge in rhinoplasty

BACKGROUND

Although several methods have been described to address nasal dorsum augmentation and smoothing of irregularities in rhinoplasty, establishing the ideal method has proven controversial.

OBJECTIVE

Here, we introduce a novel technique of cartilage grafting for nasal dorsum augmentation by wrapping cartilage in a fibrinogen- and thrombin-coated collagen patch called TachoSil®.

MATERIAL AND METHODS

In a pilot study comprising ten cases, the use of the collagen patch was examined in various indications in rhinoplasty. Patients were clinically monitored for up to 8 months and photometric and sonographic documentation was performed pre- and postoperatively.

RESULTS

In nine patients, the collagen patch was used for fixation of cartilage grafts in different indications: saddle nose deformities (n = 5), open roof (n = 1), nasal dorsum irregularities (n = 3). A diced cartilage graft enclosed by a bilayer of TachoSil® was applied in seven patients. Solid pieces of cartilage were either embedded in a bilayer of the collagen patch (n = 1) or covered by a monolayer (n = 1). Moreover, the collagen patch alone served as a soft tissue support in one patient with thin skin. Six patients were revision cases. All patients had uneventful healing without adverse events such as allergic reactions and infections.

CONCLUSION

The collagen patch TachoSil® is eligible for various indications in rhinoplasty. It is a useful material predominantly for nasal dorsum augmentation by sandwiching diced or solid cartilage in the collagen patch, leading to better graft fixation and precise profile shaping. At the same time, TachoSil® helps with blood control. Follow-up studies will be performed to assess the material's long-term behavior.

Scaffold-Assisted Artificial Hair Implantation in a Rat Model

IMPORTANCE

Current treatments for alopecia with autograft hair transplantation face limitations that may preclude complete hair restoration and leave patients with donor site scars. Scaffold assisted artificial hair implantation as demonstrated in a rat model may provide an adjunct for hair restoration without donor site morbidity.

OBJECTIVE

To design and create porous high-density polyethylene (PHDPE) and expanded polytetrafluoroethylene (ePTFE) hair-bearing scaffolds and evaluate their biocompatibility in a rat model.

DESIGN, SETTING, AND PARTICIPANTS

For this single-institution randomized prospective animal study, 34 Sprague Dawley rats were randomly selected into 2 groups: 24 rats for direct implantation and 10 rats for delayed implantation. The direct-implantation group was randomly divided into 3 subgroups of 8 rats, which were observed for 2, 12, and 24 week.

INTERVENTIONS

Each rat dorsum was implanted with 4 scaffolds-PHDPE and ePTFE with and without hair-in a randomized 4-quadrant manner. The rats in the direct-implantation group were observed to their selected time points of 2, 12, and 24 weeks. The rats in the delayed-implantation group were observed for 4 weeks at which, all well-healed scaffolds without hair were then percutaneously implanted with 2 follicular units of hair. These rats were then observed for another 4 weeks.

MAIN OUTCOMES AND MEASURES

During the clinical observation period, scaffolds were observed for signs of infection, extrusion, and persistence of follicular units. Following sacrifice, sagittal sections of scaffold and surrounding skin were fixed in formalin, stained with hematoxylin-eosin, and evaluated for degree of fibrovascular invasion and acute and chronic inflammation.

RESULTS

Overall 94.5% (86 of 91) of the scaffolds were well healed at time of evaluation (2 week, 100% [32 of 32]; 12 week, 96.3% [26 of 27]; 24 week, 87.5% [28 of 32]); while 85.6% of artificial hair follicular units were intact at time of evaluation (2 week, 93.8% [30 of 32]; 12 week, 86.7% [26 of 30]; 24 week, 75.0% [21 of 28]). Within the delayed implant group 100% (19 of 19) of the hair-implanted scaffolds were well healed at 8 weeks, with 94.7% (36 of 38) of the follicular units intact; 100% of the delayed-hair implant scaffolds were well healed with 86.1% (36 of 38) of the follicular units intact. Kaplan-Meier log-rank analysis showed no significant difference in survival between ePTFE and PHDPE scaffolds, as well as scaffolds with hair and scaffolds without hair. Upon histological analysis, overall scaffolds with hair were noted to have greater chronic inflammation (95% CI, -0.81 to -1.10; P = .01), and PHDPE was noted to have significantly great fibrovascular integration (95% CI, -11.42 to -1.96; P = .01) compared with ePTFE.

CONCLUSIONS AND RELEVANCE

Overall, PHDPE and ePTFE hair bearing scaffolds were well tolerated in a rat model. Progressive loss of artificial hair may be percutaneously implanted without significant increases in infection or extrusion.

LEVEL OF EVIDENCE

NA.

The Application of Fibrin/Hyaluronic Acid-Poly(l-Lactic-co-Glycolic Acid) Construct in Augmentation Rhinoplasty

Although many graft materials have been used for augmentation rhinoplasty, an ideal graft has not yet been developed. As the field of tissue engineering has been developing, it has been applied to the reconstruction of many organs, but its application in the rhinoplasty field is still limited. This study evaluated the utility of allogenic chondrocytes with fibrin/hyaluronic acid (HA)-poly(l-lactic-co-glycolic acid) (PLGA) constructs in augmentation rhinoplasty. Chondrocytes from rabbit auricular cartilage were isolated and cultured with fibrin/HA hydrogels and implanted into PLGA scaffolds. After 8 weeks of in vitro culture, the scaffolds were implanted in the nasal dorsum of six rabbits. Eight weeks postoperatively, the implanted sites were evaluated with gross, radiologic, and histologic analysis. In vitro, more than 90% of the seeded chondrocytes in the PLGA scaffolds survived for 2 weeks, and they produced a large amount of extracellular matrix and were well differentiated. The grafts maintained their initial shape for 8 weeks after implantation. Radiological and histological evaluations showed that the structure was well maintained with minimal inflammatory response and appropriate elevation levels. However, the formation of neo-chondrocytes was not observed. PLGA scaffolds seeded with fibrin/HA and allogenic chondrocytes can be a biocompatible augmentation material in rhinoplasty in the future.

Reconstruction of Mandibular Contour Using Individualized High-Density Porous Polyethylene (Medpor®) Implants Under the Guidance of Virtual Surgical Planning and 3D-Printed Surgical Templates

BACKGROUND

The mandibular contour plays a significant role in the beautiful and youthful look but the reconstruction remains a challenging problem. The objective of this study was to evaluate the use of individualized high-density porous polyethylene (Medpor^®) implants for comprehensive reconstruction of mandibular contour with the aid of computer-aided design/computer-aided manufacturing (CAD/CAM).

METHODS

From 2010 to 2014, 12 patients with mandibular contour deformities were enrolled in our retrospective study. Mandible models and individualized surgical templates were fabricated by three-dimensional (3D) printing and Medpor^® implants were made according to the surgical templates. The Medpor^® implants were used for both unilateral and bilateral mandibular contour deformities. In four cases, simultaneous mandibular orthognathic surgery was performed with unilateral mandibular contour reconstruction.

RESULTS

Eleven patients had a reposeful postoperative recovery with no complication. Delayed infection was shown in one patient and the Medpor^® implant was removed. All the 11 patients had the mandibular contour reconstructed satisfactorily.

CONCLUSION

The technique and cases presented demonstrate the utility of Medpor^® implants with CAD/CAM in comprehensive mandibular contour reconstruction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases

BACKGROUND

Modern rhinoplasty is not just a reduction procedure. An optimal nasal esthetic result occasionally requires augmenting the nasal tip, the dorsum or the lateral wall with autografts or alloplasts. A large number of nasal implant types have been reported in the medical literature.

OBJECTIVE

The goal of this article is to demystify the role and indications of nasal implants in rhinoplasty. As well, it offers both the novice and experienced nasal surgeon a basic, simplified and organized approach to the use of soft and firm nasal implants in rhinoplasty.

METHODS

This article presents the authors experience with 311 rhinoplasties using both soft and firm alloplastic implants. The indications for both types of alloplasts are discussed, the surgical technique detailed and the outcomes analyzed.

RESULTS

A total of 311 nasal implant cases were reviewed. This series revealed a low incidence of postoperative infection (5.57% for soft implants and 0.1% for the firm ones). The revision rate was 2.7% for the soft implants group and 7.1% for the firm implants group.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Contracted Nose after Silicone Implantation: A New Classification System and Treatment Algorithm

Background

Silicone implants are frequently used in augmentation rhinoplasty in Asians. A common complication of silicone augmentation rhinoplasty is capsular contracture. This is similar to the capsular contracture after augmentation mammoplasty, but a classification for secondary contracture after augmentation rhinoplasty with silicone implants has not yet been established, and treatment algorithms by grade or severity have yet to be developed.

Methods

Photographs of 695 patients who underwent augmentation rhinoplasty with a silicone implant from May 2001 to May 2015 were analyzed. The mean observation period was 11.4 months. Of the patients, 81 were male and 614 were female, with a mean age of 35.9 years. Grades were assigned according to postoperative appearance. Grade I was a natural appearance, as if an implant had not been inserted. Grade II was an unnatural lateral margin of the implant. Clearly identifiable implant deviation was classified as grade III, and short nose deformation was grade IV.

Results

Grade I outcomes were found in 498 patients (71.7%), grade II outcomes in 101 (14.5%), grade III outcomes in 75 (10.8%), and grade IV outcomes in 21 patients (3.0%). Revision surgery was indicated for the 13.8% of all patients who had grade III or IV outcomes.

Conclusions

It is important to clinically classify the deformations due to secondary contracture after surgery and to establish treatment algorithms to improve scientific communication among rhinoplasty surgeons. In this study, we suggest guidelines for the clinical classification of secondary capsular contracture after augmentation rhinoplasty, and also propose a treatment algorithm.

Pre-operative in vitro fibroblast coating of porous polyethylene compound grafts - Cell survival in vivo and effects on biocompatibility

BACKGROUND

Key factors for successful porous polyethylene (PPE) implantation are rapid vascularization and low inflammatory response. Dermal fibroblasts produce a variety of pro-angiogenic and immunmodulatory factors.

OBJECTIVE

The aim of this tissue engineering study was to investigate whether coating PPE implants with dermal fibroblasts in vitro is sustainable in vivo and whether the kinetics of blood vessel ingrowth and immunological responses are hereby affected.

METHODS

PPE implants were cultured with syngeneic GFP-transfected dermal fibroblasts. Cells on the biomaterial were quantified before implantation into dorsal skinfold chamber preparations of C57Bl/6 mice. Uncoated implants served as controls. Angiogenic activity and leukocyte-endothelial cell interactions were repeatedly analyzed. After 10 days, mechanical integration was measured and surviving fluorescently labeled fibroblasts were quantified. Expression of inflammatory cytokines was assessed by quantitative real time-reverse transcription PCR.

RESULTS

PPE implants were successfully coated with dermal fibroblasts in vitro and 69% of the cells were still detectable at the end of observation. Angiogenic parameters increased during the observation period in both groups. IL-2, IL17A and IL-10 tended to be increased in coated implants, but did not affect leukocyte-endothelial cell interactions.

CONCLUSIONS

Dermal fibroblast-coating of porous polyethylene implants is feasible and sustainable in vivo. Alone it does not improve biocompatibility but may be beneficial in combination with specific growth factor supplements.

Histological Comparison of Implanted Cadaveric and Porcine Dermal Matrix Grafts

OBJECTIVES: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials.

STUDY DESIGN: In vivo, rat model.

METHODS: Subcutaneous implantation of 1-mm thick, 1 cm X 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively.

RESULTS: AlloDerm showed significantly greater soft tissue in-growth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks ( P < 0.001).

CONCLUSIONS: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model.

Controversies in Revision Rhinoplasty

Revision rhinoplasty is a complex operation with many variables that may influence the final esthetic and functional outcome of the procedure. Cartilage forms the structural framework of the lower two-thirds of nose and is essential for long-term support and maintenance of a patent nasal airway. The use of autologous cartilage grafting is the primary source of this material, limited by donor site quantity, quality, and harvest morbidity. Alloplastic materials, solid and injectable, are often used for augmentation purposes and may have devastating consequences. This article discusses past and current treatment concepts for various nasal deformities using available autologous grafting techniques.

Clinical effectiveness and safety of collagen sheet for dorsal augmentation in rhinoplasty

In Asian rhinoplasty, dorsal augmentation often requires the use of alloplastic materials because sufficient amounts of autograft are difficult to harvest. Given considerations of aesthetics, costs, and the characteristics of the oriental nose, silicone or Gore-Tex is commonly used when augmenting the nasal dorsum to a great extent. Such materials can often result in postoperative complications and foreign-body sensations. Moreover, extrusion or visualization of the implant may occur because of thinning of the skin over time. Permacol collagen implants are specifically indicated for soft tissue reinforcement and repair of the head and face in plastic and reconstructive surgery. The handling versatility of the flexible collagen sheet allows it to be layered over itself until the requisite thickness and desired shape are obtained. A total of 50 patients who underwent nasal augmentation rhinoplasty between December 2007 and May 2011 were observed for at least 24 months. Depending on the nasal dorsum, we layered the collagen sheet up to a maximum of 4 times and we have not seen any case of severe resorption or overcorrection in the nasal configuration. Collagen implant material is safe for use in select rhinoplasty patients because of its low complication rate, as shown in our series. It could therefore be considered as a useful alternative when reconstruction is problematic because of the low quality or lack of available autologous grafts.

Treatment of gummy smile: Nasal septum dysplasia as etiologic factor and therapeutic target

Various techniques to improve gummy smile exist. Depending on the individual etiology, previous approaches have focused on osseous, dental, and soft-tissue aspects. On the basis of the identification of nasal septum dysplasia as etiologic factor of gummy smile, we propose a novel strategy for the improvement in the treatment of excessive gingival exposure. In this prospective controlled study, 121 Asian patients with gummy smile and 150 volunteers were examined and compared with regard to the developmental status of the nasal septal cartilage reflected by the columella upward maximum movability (CUMM) as objective measurement parameter. A total of 46 patients with significantly increased CUMM underwent surgical treatment for excessive gingival exposure by septum cartilage reinforcement and, where required, additional extension using an autologous cartilage graft or an expanded polytetrafluoroethylene (ePTFE) implant. Gingival exposure at the fullest smile was photographed, measured, and analyzed before and 1, 3, and 6 months after surgery, and all possible complications were recorded. The results were evaluated in a patient satisfaction survey. CUMM showed a significant statistical difference between the patients desiring treatment for gummy smile (5.6 ± 0.92 mm) and volunteers (3.1 ± 0.76 mm), (p < 0.05). In the 46 patients who underwent surgical correction of gummy smile, the measured maximum gingival exposure at the fullest smile was 4.52 ± 1.7 mm preoperatively and significantly decreased to 1.79 ± 0.26 mm at 6 months postoperatively (p < 0.05). The overall complication rate was low, including transient stiffness of smile, implant deformation, and acute infection. The postoperative results were highly satisfactory in terms of aesthetic smile. This study proposes a novel strategy of reinforcement and extension of the nasal septum cartilage for the improvement of gummy smile confirming septal cartilage dysplasia as the etiologic factor.

Cultured chondrocyte and porcine cartilage-derived substance (PCS) construct as a possible dorsal augmentation material in rhinoplasty: A preliminary animal study

As there is no single ideal material for dorsal augmentation in rhinoplasty, there has been a continuing need for the development of improved materials. Therefore, we aimed to evaluate the outcome of using a novel tissue-engineered construct composed of autologous chondrocytes cultured with a porcine cartilage-derived substance (PCS) scaffold as an augmentation material in rhinoplasty. A scaffold derived from decellularized and powdered porcine articular cartilage was prepared. The rabbit articular cartilage was used as the source of homologous chondrocytes, which were expanded and cultured with the PCS scaffold for 7 weeks. The chondrocyte-PCS constructs were then surgically implanted on the nasal dorsum of six rabbits. Four and eight weeks after implantation, the gross morphology, radiologic images, and histologic features of the site of implant were analyzed. The rabbits showed no signs of postoperative inflammation and infection. The degree of dorsal augmentation was maintained during the 8-week postoperative observation period. Postoperative histologic examinations showed chondrocyte proliferation without an inflammatory response. However, neo-cartilage formation from the constructs was not confirmed. The biocompatibility and structural features of tissue-engineered chondrocyte-PCS constructs indicate their potential as candidate dorsal augmentation material for use in rhinoplasty.

Rhinoplasty: panel discussion

Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?

Revision rhinoplasty: panel discussion, controversies, and techniques

What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose--when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?'

ANALYSIS

Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?

Management of complications from alloplastic implants in rhinoplasty

PURPOSE OF REVIEW

Alloplasts have long been used in rhinoplasty, but their use remains controversial. Many complications are associated with their implementation in rhinoplasty. This article elucidates these complications and provides recommendations for management.

RECENT FINDINGS

Several recent articles have been published presenting experience and outcomes regarding alloplast use in rhinoplasty. In many of these studies, a specific section has been dedicated to outlining the complications encountered by the authors. Oftentimes, a short summary of the complications and their management is provided. By examining the data from these studies, one can conclude several things about the management of complications involving alloplastic implants in rhinoplasty: each case must be approached on an individual basis; clinical decision-making is dictated by physical exam findings and severity of the complication; removal of the implant must be strongly considered; and revision rhinoplasty after an alloplastic complication usually necessitates an autologous graft.

SUMMARY

Alloplasts continue to be a controversial option in rhinoplasty. The surgeon must be cognizant of the risks and benefits of their use. A frank preoperative discussion of possible complications with the patient is important. Additionally, prompt recognition and appropriate management of complications is essential to minimize permanent sequelae.

Nasal reconstruction using tissue engineered constructs: an update

Currently, the gold standard for reconstruction after rhinectomy or severe trauma to the nose, includes transposition of autologous mucosal flaps plus autologous cartilage grating and coverage using a skin flap. Difficulties with this approach arise where; cartilage and mucosa harvested from autologous donor sites is insufficient to achieve a passable aesthetic and functional reconstruction. Skin flaps are often bulky, poor color matches with hair follicles that reduce the aesthetic quality of the reconstruction. We suggest that tissue engineering could be a source of functional replacement tissues for nasal reconstructive surgery. However, the advancement of such an approach is dependent on the dissemination of scientific information into the clinical community, regarding the engineering of tissues such as mucosa, skin, and cartilage. This paper therefore reviews how the tissue engineering strategies available for producing clinically viable tissues could help resolve issues around reconstructing the human nose.

Acquired defects of the nose and naso-orbitoethmoid (NOE) region

Nasal injuries coupled with midface fractures of the orbit and ethmoids constitute a nasoorbitoethmoid (NOE) fracture pattern, which is typically the most challenging facial fracture to repair. Hard and soft tissue defects of this region may require advanced reconstruction techniques, including local rotational flaps, free tissue transfer, and even prosthetics. The restoration of form and function dictates treatment, and the success of primary repair is paramount, because secondary correction is challenging in this area of the midface. Because of the complex nature of this region, this discussion is divided into hard tissue defects, with a focus on trauma, and soft tissue defects, with a focus on oncology.

Imaging of cosmetic facial implants and grafts

SUMMARY

A wide variety of implants and grafts have been used for cosmetic facial surgery, including forehead, nose, cheek, lip, and chin augmentation. Some of the implant materials include silicone, expanded polytetrafluoroethylene (Gore-Tex), hydroxylapatite, and porous polyethylene (Medpor). Grafts include bone and cartilage, which can be prepared as "Turkish Delight" for rhinoplasty. Imaged facial implants and grafts can be encountered incidentally or purposely to evaluate complications. Many of these materials have distinct radiologic imaging features and should not be misinterpreted as pathology. Conversely, implant complications should be appropriately recognized by using a focused imaging approach. The purpose of this article was to review the different types of cosmetic facial implants and grafts with an emphasis on their expected and complicated radiologic imaging appearances.

Two New Polymers as Candidates for Rhinoplasty Allografts: An Experimental Study in a Rabbit Model

Objectives:

This study was performed to evaluate the biocompatibility and tensile strength of two new polymeric materials — A polyfluoro ether-modified thermoplastic polyurethane urea and a polydimethyl silicone elastomer — In an experimental rabbit model.

Methods:

The two polymers were implanted inside separate subperichondrial pockets created over the auricular cartilages of 12 rabbits. A control pocket received no implant. After 3 months, the animals were painlessly sacrificed, and each site was analyzed histologically for vascular congestion, acute and chronic inflammation, and fibrosis in the tissue surrounding the implant materials.

Results:

There were no statistically significant differences in vascular congestion, fibrosis, or acute or chronic inflammation between the control sites and either implant site.

Conclusions:

These results suggest that the polymers are well accepted by the tissue and remain stable during the entire study period, and that they could be very suitable materials for use in nasal reconstruction.

Ultrasonographic monitoring of new expanded polytetrafluoroethylene implant thickness after augmentation rhinoplasty

BACKGROUND

Expanded polytetrafluoroethylene (e-PTFE) is currently one of the most popular implant materials for rhinoplasty. Surgiform (Surgiform Technology, Ltd., Lugoff, SC) is a recently introduced ePTFE material with physical characteristics that are slightly different from Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ). Changes in Surgiform thickness after rhinoplasty are not well documented.

METHODS

This prospective study enrolled 16 patients (12 male and 4 female patients) who underwent primary augmentation rhinoplasty with Surgiform. High-resolution ultrasonography was used to measure implant thickness after a mean follow-up period of 14.7 months (range, 8-21 months).

RESULTS

Surgiform implants were easily and clearly demarcated from surrounding tissue. The mean thickness of inserted implants was 2.37 ± 0.80 mm at the rhinion and 3.12 ± 1.26 mm at the supratip. The follow-up thickness was 2.35 ± 0.77 mm at the rhinion and 3.09 ± 1.23 mm at the supratip. Implant thickness did not decrease significantly at the rhinion (p = 0.112) or the supratip (p = 0.165).

CONCLUSION

Ultrasonographic monitoring indicated that Surgiform e-PTFE does not shrink significantly over time.

Imaging features of rhinoplasty

SUMMARY

Cosmetic rhinoplasty encompasses a diverse group of procedures, including alteration of the radix, nasal dorsum, nasal tip, and nasal base; premaxillary augmentation; septoplasty; and combinations thereof. Similarly, many different types of grafts and alloplastic materials can be used in cosmetic rhinoplasty, such as cartilage, bone, silicone, porous polyethylene, expanded polytetrafluoroethylene, and calcium hydroxylapatite. Complications of rhinoplasty that can be observed on imaging include retained metallic surgical instrument fragments, infection, implant extrusion, nerve impingement by implants, nasal valve collapse, and implant deformity. Knowledge of the basic surgical procedures and potential complications of cosmetic rhinoplasty is important for adequately interpreting postoperative radiologic imaging studies.

Reconstruction of internal nasal valve, septum, dorsum, and anterior structures of the nose in a single procedure with a molded bone graft: the sail graft

Excessive surgical removal or traumatic loss of the tissues supporting the nasal roof can result in the "saddle nose" deformity. It involves both cartilage and bone deficiencies. Two main resources are used to reconstruct this difficult deformity: autogenous bone and cartilage grafts and alloplastic materials. This study presents the reconstruction of the dorsum, septum, internal nasal valve, and anterior structures and the tip of the nose using a block of molded autogenous bone graft. We called it the "sail graft," because it looks like a sail from a lateral view. The mast of the sail is oriented in a superior-to-inferior direction, beginning in the frontonasal region to the tip of the nose to form a straight, well-rounded dorsum. The longest postoperative follow-up of 13 cases is now 10 years; the median follow-up is 2 years. The results have been satisfactory.

Histomorphological Changes of Tutoplast-Processed Fascia Lata Grafts in a Rabbit Rhinoplasty Model

Objectives

Tutoplast-processed fascia lata (TPFL) is a commercially available homograft that has been successfully used as graft tissue for rhinoplasty. The present study evaluates the histomorphological changes of TPFL in a rabbit rhinoplasty model.

Study Design

Prospective study using a rabbit model.

Setting

Animal laboratory of the Asan Medical Center.

Subjects and Methods

The study used 15 New Zealand White rabbits. Each rabbit was implanted with a TPFL (experimental group) and autologous fascia lata (control group) graft of equal size into the nasal dorsum. Rabbits were killed at 1, 3, and 6 months, and the grafts were removed and microscopically assessed for fibroblast proliferation, neovascularization, inflammation, and thickness.

Results

For TPFL grafts, the degree of inflammation significantly decreased between 1 and 3 months ( P = .041). The degree of fibroblast proliferation continually increased over time. There was a mild degree of neovascularization for the TPFL graft at 1 month. The degree of neovascularization increased between 3 and 6 months ( P = .041). For the degree of inflammation, fibroblast proliferation, and neovascularization, there was no significant difference between TPFL and autologous fascia lata at 6 months. Mean thickness analysis showed that there was no significant thickness reduction in both TPFL and autologous fascia lata grafts at 6 months.

Conclusion

The TPFL grafts showed negligible resorption rates and favorable tissue reactions in the rabbit rhinoplasty model.

Salvage of calvarial bone graft using acellular dermal matrix in nasal reconstruction and secondary rhinoplasty for frontonasal dysplasia

Frontonasal dysplasia is a severe malformation composed of cranial, ophthalmic, nasal, upper lip, and palatal deformities. Reconstruction in these patients requires complex craniofacial efforts. A 19-year-old woman with frontonasal dysplasia was treated at our institution where she had undergone multiple prior reconstructive surgeries including facial bipartition and cantilevered calvarial bone graft for nasal reconstruction. She later presented with a palpable bone graft prominence, associated contour deformity, and an area of overlying paper-thin skin at the nasal tip. Although there was no ulceration, the threat of graft extrusion required immediate attention. The prominent bone graft tip was debrided, and the overlying soft tissue envelope was augmented using acellular dermal matrix. No surgical complication was encountered. The patient had successful salvage of the bone graft and a pleasing aesthetic outcome at 9 months of follow-up. The use of acellular dermal matrix has proven to be beneficial in the correction of nasal contour deformities given its soft, natural appearance, availability, affordability, and safety. Its use also avoids further donor site morbidity. We suggest acellular dermal matrix as a graft material in revision rhinoplasties for cases of acquired nasal contour deformity and threatened bone graft extrusion. This is the first report known to the authors using acellular dermal matrix during staged nasal reconstruction in a patient experiencing frontonasal dysplasia.

Advancing nasal reconstructive surgery: the application of tissue engineering technology

Cartilage tissue engineering is a rapidly progressing area of regenerative medicine with advances in cell biology and scaffold engineering constantly being investigated. Many groups are now capable of making neocartilage constructs with some level of morphological, biochemical, and histological likeness to native human cartilage tissues. The application of this useful technology in articular cartilage repair is well described in the literature; however, few studies have evaluated its application in head and neck reconstruction. Although there are many studies on auricular cartilage tissue engineering, there are few studies regarding cartilage tissue engineering for complex nasal reconstruction. This study therefore highlighted the challenges involved with nasal reconstruction, with special focus on nasal cartilage tissue, and examined how advancements made in cartilage tissue engineering research could be applied to improve the clinical outcomes of total nasal reconstructive surgery.

Diced cartilage grafts wrapped in AlloDerm for dorsal nasal augmentation

Dorsal nasal augmentation is commonly performed for various aesthetic deficiencies and/or reconstructive defects such as the saddle nose deformity. However, the optimal technique for volume augmentation has yet to be identified. The senior author (F.P.) has since developed a new modified technique using wrapped diced cartilage within an AlloDerm. This novel construct provides the plastic surgeon a smooth, convenient, pliable option with similar operative times as compared with other popular techniques. In summary, this technique has been proven to be successful in achieving attractive, safe, and acceptable outcomes in nasal dorsal configuration and overall patient satisfaction.

Structural grafts and suture techniques in functional and aesthetic rhinoplasty

Rhinoplasty has undergone important changes. With the advent of the open structure approach, requirements for structural grafting and direct manipulation of the cartilaginous skeleton through suture techniques have increased substantially. The present review analyzes the current literature on frequently referenced structural grafts and suture techniques. Individual techniques are described and their utility is discussed in light of available studies and data.

[Porous polyethylene implants for ear reconstruction of middle to high-grade ear defects]

The incidence of middle to high-grade ear malformations in Germany is approximately 150 per year. For many years autologous rib cartilage has been used for ear reconstruction as a framework material. In spite of a good biocompatibility of autologous rib cartilage there are potential risks of framework deformity as well as donor site morbidity. The advantages of osseo-integrated implants have provided patients with predictable esthetic results, durability and improved retention of the ear prostheses. Porous polyethylene ear implants (Medpor®) have been used for over 20 years as a suitable framework material. The advantages of this promising technique are good biocompatibility, short hospitalization time and the possibility of a one-step reconstruction of total or subtotal ear defects. The reconstruction of ear malformations with porous polyethylene ear implants is possible even in patients over 6 years old. Moreover, polyethylene promotes revascularization due to its porous structure, resulting in a good incorporation at the implantation site. The use of porous polyethylene ear implants permits a more expedient, less invasive and reliable reconstruction in moderate or high-grade ear malformations with very convincing results.

Use of silicone sizers in implantation of porous polyethylene nasal dorsal implants in asians

Introduction. A new technique of implantation of high-density porous polyethylene nasal dorsal implants in Asians is described in this paper. Silicone sizers, which have smooth surfaces, were used to facilitate implantation of porous polyethylene implants in Asian patients. Materials and Methods. Twenty-three patients of Asian descent underwent dorsal augmentation rhinoplasty with open technique using high-density porous polyethylene implants. In all cases, silicone sizers were used to facilitate implantations of high-density porous polyethylene nasal dorsal implants. Patient selection criteria exclude patients with history of cocaine use, history of nasal or sinus disorders, previous nasal surgery, deviated septum, poor cartilage support, and thin skin. Results. No bleeding, infection, rejection, displacement, or extrusion was noted. One implant was removed because of a patient's dissatisfaction with the resulting tip height. Conclusion. The use of silicone sizers to facilitate implantations of high-density porous polyethylene nasal dorsal implants was safe and efficacious.

Biocompatibility of porous polyethylene implants tissue-engineered by extracellular matrix and VEGF

Rapid ingrowth of blood vessels and low inflammatory response are considered major prerequisites for successful implantation of biomaterials in reconstructive surgery. Aim of the present study was to evaluate whether tissue-engineered porous polyethylene (PPE) implants providing extracellular matrix components (ECM) and vascular endothelial growth factor (VEGF) in vivo improve microvascular ingrowth and mechanical integration with regard to initial inflammatory responses. PPE implants (3 x 3 x 0.1 mm(3), pore size approximately 100-200 microm) were tissue-engineered by incorporation of ECM components (GFR-Matrigel) adding recombinant murine VEGF (1 microg/mL) and grafted into dorsal skinfold chamber preparations of C57BL/6 mice. Control animals received uncoated implants or implants coated with ECM components alone (n = 6 per group). Using in vivo fluorescence microscopy angiogenic activity and inflammatory leukocyte-endothelial cell interactions were analyzed for 2weeks. Finally, mechanical integration was quantified by measurement of dynamic desintegration strengths at the host-implant border. Functional vessel density, red blood cell velocity, and vessel diameters increased continuously in all groups indicating that rapid microvascular integration of PPE occurred even without incorporation of ECM or VEGF. However, a transient initial inflammatory response with increased leukocyte-endothelial cell adherence on day 7 in uncoated control implants was efficiently reduced by incorporation of ECM and VEGF. Measurement of dynamic breaking strengths revealed no significant differences between the groups although there was a tendency to improved mechanical integration in tissue-engineered implants. Therefore, novel tissue- engineered constructs of PPE implants providing ECM and VEGF in high local concentrations can increase biocompatibility especially under unfavorable conditions for implantation.

Anchor-shaped nasal framework designed for total nasal reconstruction

BACKGROUND

Nasal frame grafting has been widely used in nasal reconstruction; however, a stable nasal frame with satisfactory functional and aesthetic results is hard to achieve in total nasal reconstruction. In this study, we devised a technique to create an individually designed anchor-shaped nasal frame composed of an L-strut and two C-battens, and applied it in the total nasal reconstruction procedure to achieve satisfactory functional and aesthetic results.

METHOD

In a 9-year period, 17 patients with total nasal defect were treated with autogenous costal grafting utilising forehead flap as the covering. The techniques of the individualised design of the anchor-shaped nasal frame were applied to fit the facial features. All cases were followed for at least 18 months, and outcomes were evaluated separately by the patients and plastic surgeons in terms of aesthetics, stability and function.

RESULTS

Satisfactory results were achieved in most of the cases after the operation. More than 82.4% of the patients in this series were assessed as satisfactory by both groups in the aesthetics survey; more than 76.5% in the stability survey; and more than 64.7% in the function survey. Complications included flap hyperpigmentation (one case), flap-skin paleness (one case), L-strut distortion (three cases) and stuffiness of the nostrils (one case) as well as minor brow elevation of the donor side (five cases).

CONCLUSIONS

The procedure of applying individually designed anchor-shaped nasal frame with forehead flap technique has obvious advantages for restoration of distinct and delicate subunits, stable nasal structure and good nasal function.

Alar batten cartilage graft: treatment of internal and external nasal valve collapse

BACKGROUND

The aim of this study was to describe the efficacy of alar batten graft in correcting internal and external nasal valve collapse (i.n.v. and e.n.v.) and evaluate the functional and aesthetic results.

METHODS

From July 2006 to September 2008, 80 patients (54 females and 26 males) underwent alar batten cartilage grafting. The patients were divided into three groups: (1) 55 patients with iatrogenic nasal valve collapse (80% i.n.v., 20% e.n.v.), (2) 15 patients with posttraumatic nasal valve collapse (45% i.n.v., 55% e.n.v.), and (3) 10 patients with congenital nasal valve collapse (100% e.n.v.). Patients were evaluated at 6, 12, 24, and some at 36 months after surgery. The final follow-up was at least 24 months.

RESULTS

The results of this study revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of alar batten grafts. All the patients noted improvement in their nasal airway breathing and in their cosmetic appearance. No major complication was observed.

CONCLUSION

The alar batten graft is a simple, versatile technique for long-term reshaping, repositioning, and reconstruction of the nasal valve collapse.