Nasal Implants
Introduction
The nose is critically involved in appearance, both to oneself and to others, and it is significantly involved in the perception of beauty both publicly and privately. Because of its central location on the face, plane of projection, and relatively weak chondrocutaneous support structure, the nose is susceptible to injury, and deformities are readily apparent.
Whatever the circumstances that led to the nasal deformity, the complex tasks of assessing the patient's nasal anatomy, pathologic defect, aesthetic qualities, baseline perception, planning the reconstruction, and preparing the patient for the possible positive and negative outcomes can be daunting. In planning for nasal reconstruction requiring an implant, careful decisions need to be made regarding the types of materials to substitute for support. Final soft-tissue coverage of the planned reconstruction is of paramount importance in the preparation.
History of the Procedure
In northern India, during the 6th century BC, Susruta focused on soft-tissue augmentation for amputation injuries and nasal reconstruction.1
In the 16th and 17th centuries, Tagliocozzi used a tubed pedicle flap and Carpue, an Englishman, reinstituted the forehead flap.2,3
Various nonautogenous materials have been employed over the centuries to improve reconstruction of the nose by providing bridge support. Early attempts at finding the ideal or most suitable nasal implant for bridge construction included trials of materials such as paraffin, gold, silver, aluminum, ivory, cork, stones from the Black Sea, polyethylene, rubber, silicone, lead, and a toothbrush handle.
Currently, general categories of available materials include autografts, homografts, and allografts. This article covers the variety of materials commonly employed. The pros and cons of various materials are detailed and illustrated.
Problem
The choice of nasal implants to be placed in reconstructive surgery of the nose is a difficult but important component in the patient's care. The degree of loss noted in tip support, bridge contour, or nasal valve collapse may mandate implant use in nasal reconstruction. Each of the various materials has benefits and pitfalls, which must be balanced against the surgeon's familiarity with each material. Because of the nose's central location, minor defects of reconstruction may be particularly noticeable to any casual observer but may play a much larger role psychologically in the patient's perception of self. Based on the authors' review of the literature and clinical experience, autogenous cartilage and/or bone are recommended as the primary choices for nasal implants.
Indications
Although the major underlying cause of nasal reconstruction is trauma, a number of pathologic entities traditionally have required surgical nasal reconstruction (eg, congenital malformations, malignant destruction, septal perforations, granulomatous disease, congenital syphilis, leishmaniasis, leprosy). Whatever the cause of the defect, nasal reconstruction with or without various implant materials allows restoration of function along with restoration of an aesthetically critical component of the face.
Relevant Anatomy
A prerequisite to nasal reconstruction is familiarity with nasal anatomy and proportions. The nose is generally divided by anatomic units into thirds. The upper third of the nose, or bony vault, is represented by the paired nasal bones that overlie the nasal spine of the frontal bone. The cartilaginous vault represents the lower two thirds of the nose, with the middle third being the region of the upper lateral cartilages, and the lower third involving the nasal tip, septum, and lower lateral (alar) cartilages. The general function of the nose is to warm and humidify incoming air. To achieve both form and function, the nasal vestibule should comprise approximately one half to two thirds of the nasal lobule as viewed from the basal projection. Attention should be dedicated to reconstructing the columella, tip, and ala to form an adequate nostril internally while incorporating aesthetics externally.
Contraindications
Ongoing infection or conditions requiring further therapy (eg, serial débridements) are examples of contraindications to reconstruction. Address patient stabilization and optimization, including nutritional status when possible, prior to surgical intervention. Therapies such as radiation or chemotherapy should be completed prior to reconstruction.
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