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KAREN H.CALHOUNMDRONALD B.KUPPERSMITHMDFrom the Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Tex.
Autogenous grafts are preferable to synthetic materials in rhinoplasty.
Over the past 15 years, grafts have been used with increasing frequency during rhinoplasty procedures as the transition has been made from reductive rhinoplasty to augmentation or restructuring rhinoplasty. There are a number of grafting materials available, including autogenous materials (bone, cartilage), homograft materials (rib cartilage, dermis), and a wide variety of synthetic or alloplastic materials. With regard to the autogenous materials, cartilage has been the mainstay for augmentation in rhinoplasty. Bone is used infrequently because it often yields unsatisfactory results in the aesthetic appearance of the nose, and has problems with graft resorption.1 I will therefore not discuss bone herein. This article focuses on the differences between autogenous cartilage implants and synthetic materials, in particular expanded PTFE (Gore-tex; WL Gore & Associates Inc, Flagstaff, Ariz).
Jennifer Parker Porter, MD
Certainly, there is no argument that autogenous grafts, in particular cartilaginous grafts, are superior as a grafting material in rhinoplasty for a variety of reasons. Cartilaginous grafts are considered the criterion standard by many authors.2-7 The more debatable issue is in the case where substantial dorsal augmentation is required: is autologous material preferable to synthetic? Arguments to both support and refute the notion that autologous cartilage is superior will be presented here.
Overall, the ideal implant7 should have biocompatible physical properties. It should retain constant shape and volume and be nonresorbable. Removal should be easy, and migration should not be a problem. As well, the implant should be easily modified and molded, readily available, and cost-effective. On a microscopic level, there should be no inflammatory response, and there should be resistance to infection. The tissue should not degrade, transmit disease, or act as a carcinogen. These characteristics apply to implants throughout the body. Another desirable characteristic with respect to the nose is that in the area of thin skin over the upper dorsum, the implant should be easily camouflaged. These issues as they pertain to both the autogenous and synthetic graft will be addressed and conclusions offered. While comparison of the aesthetic results is impossible and has not been evaluated in a series, patient satisfaction and revision rates will be emphasized.
The wide variety of synthetic materials that have been used for the purpose of rhinoplasty is an indication of the need for a perfect alloplastic implant. Through the years, numerous synthetic materials have had relatively high complication rates. I will address only 2 synthetic implants that continue to be used frequently: silicone and expanded PTFE. Silicone is widely used in rhinoplasty for the Asian patient, and the issues relative to this procedure will be addressed. Expanded PTFE has been gaining in popularity over the past 10 years, and results after long-term follow-up will be assessed.
As previously mentioned, autogenous cartilage grafts are considered the criterion standard for grafting in rhinoplasty. Because most surgeons consider them safe, most of the literature that discusses cartilage implants in rhinoplasty addresses various techniques for the use of cartilage, and not long-term results. In addition, less has been written in this regard over the past decade, possibly because of the advent of newer biomaterials with improved acceptance rates.
What is known is that the cartilage graft is nearly ideal as implantation material in rhinoplasty. When implanted as an autologous graft, it does not induce an immune response; thus, graft rejection, infection, and extrusion are rare.7 Review of the literature lends support to the other characteristics that make cartilage an ideal implant in nasal reconstruction. Autologous cartilage is pliable yet imparts structural benefits when needed.3,4 Cartilage can be used for augmentation purposes in a wide variety of procedures: tip refinement, dorsal augmentation, spreader grafts, and alar batten grafts, to name a few. Thus, cartilage autografts are versatile and superior to synthetic materials when strength and structure are needed.
The role of implanted uncrushed and crushed cartilage was evaluated in an animal model 6 weeks and 6 months after implantation.1 Histologic evaluation revealed that all specimens of uncrushed cartilage remained stable in both a subcutaneous and perichondrial pocket. Crushed cartilage remained viable and also induced neocartilage formation around and within the graft. Thus, in addition to being nonimmunogenic after implantation, the cartilage is stable over the long-term and becomes incorporated into the surrounding tissues. These properties make the graft useful in any modality and particularly for dorsal grafting because the graft has a predilection for long-term viability.
Tardy et al4 reported 17 years of experience with more than 2000 autogenous cartilage grafts in 1985. The duration of follow-up was not available in this series, but the results reveal no incidence of graft rejection or loss due to infection. Complications were infrequent and often a result of surgical errors in graft contouring, fashioning, or inaccurate and imprecise host pocket preparation. No substantial complications occurred due to the properties of the graft itself. The authors noted that complications due to surgical error lessened with increased operator experience.
More recently, Collawn et al3 evaluated 10 years of experience using cartilage grafts for nasal augmentation. Donor grafts used were from the septum, auricle, fascia, and rib with recipient sites being the tip (41%), dorsum (31%), and columella (17%). Complications requiring reoperation occurred in 17% of cases in the first 4 years of the study and 2% of cases in the last 4 years. Further examination of the complications reveals that of the 2 patients who had complications during the last 4 years of the study, one experienced a warped allograft, and the other a prominent lower cartilage. Rib autografts were frequently the cause of graft warping and as such were used less frequently in the latter portion of the study, thereby lessening the number of postoperative complications. In the first 4 years of the study, 1 graft became infected and was removed. No graft resorption occurred. The authors concluded that modification of techniques of cartilage implantation led to results that are satisfactory and stable over the long-term with a very low incidence of complications. Vuyk and Adamson's7 review of the literature reported decreased warping of the rib cartilage graft with careful contouring and removal of the outer layers of the rib cartilage.
Cardenas-Camarena and Guerrero8 evaluated 8 years of experience using cartilaginous autografts in nasal surgery (930 patients with rhinoplasty required cartilage grafting). Grafts were placed in a variety of anatomic sites with the following being the most common: 64% medial crural strut, 36% tip graft, and 19% along the dorsum. The average duration of follow-up was 4 years 3 months. Eighty-four percent of the patients were totally satisfied with their surgical outcome; 8% required secondary operations, with 3.2% of the secondary rhinoplasties resulting from to dorsal graft excess or inadequacy. There were no complications because of infection or extrusion of the grafts. Once again, surgical complications were a result of technical errors in judgment rather than properties inherent to the grafts themselves.
While most alloplastic implants are now eschewed by surgeons, 2 remain viable options. Of the 2, silicone is used less often and is associated with a higher complication rate. Nasal augmentation with silicone is primarily used in the Asian patient and is postulated to be successful in this population because of the relatively thick skin–soft tissue envelope under which the implant lies.9 Silicone use in nasal augmentation was evaluated by Deva et al9 in a retrospective study using chart analysis of 422 patients of Southeast Asian origin. The rate of early and late complications that resulted in implant removal was 9.7%. Results of a telephone survey of 63% of patients revealed that 15.8% were dissatisfied with their surgery. Deva et al9 propose that nasal augmentation with silicone is efficient and effective, but the combination of the complication rate and the patient dissatisfaction rate yields a large percentage of patients who were dissatisfied with their surgery or had bad outcomes. These rates seem unacceptably high in light of the fact that the surgery is purely elective.
Expanded PTFE is very popular as a choice for augmentation rhinoplasty when synthetic materials are desirable. The use of expanded PTFE in rhinoplasty was evaluated in a small series of patients, all with longer than 18 months' follow-up.10 Retrospective analysis of the 30 patients revealed a relatively high complication rate (20%). Half of the complications were from infections; 2 patients had increased scar tissue formation, and 1 had seroma formation. The authors devised guidelines for improving outcome and decreasing complications. However, no long-term follow-up was available for this subgroup of patients treated by the new guidelines. Again, the high rate of complications is a disincentive for use of synthetic materials in these cases where aesthetic appearance is paramount and there is a low threshold for adverse outcomes.
Several recent articles have touted the safety and efficacy of synthetic materials in rhinoplasty. While silicone and its inherent problems have been discussed within the previous section, the discussion herein will focus on the benefits of synthetic materials as a whole and the attributes of expanded PTFE. In general, synthetic materials are appealing because of their relative ease of use and ready availability in unlimited supplies. They may also be acquired without creating further morbid conditions for the patient.
Expanded PTFE is a microporous alloplastic compound, with pore sizes ranging from 10 to 30 µm, thus allowing for tissue ingrowth and graft stabilization. Neel11 evaluated the host response to graft implantation in an animal model. Twelve months postoperatively, there was minimal tissue inflammation and foreign body reaction combined with sufficient tissue ingrowth to allow for graft stabilization. He also noted that despite tissue ingrowth, the graft was easily removed when the need arose.
In a retrospective analysis, Conrad and Gillman5 examined the use of expanded PTFE in 189 patients who underwent 211 rhinoplasty procedures. The duration of follow-up ranged from 3 months to 6 years, with a mean of 17.5 months. Cases were stratified into primary and secondary rhinoplasty, of which there were 52 and 159, respectively. Most implants were placed along the nasal dorsum or nasal sidewall (54.2%). Implants were revised because of surgical technique in 4.76% of cases, and complications, including soft tissue reaction and infection, occurred in 2.7% of cases. Most complications were in secondary rhinoplasties (5 of 6). All but 1 patient (for whom the implant was removed and not replaced) were "quite pleased" with the aesthetic appearance of their noses. Modification of implantation technique has led to fewer revisions secondary to surgical technique.
More recently, Godin et al12 reported 10 years of experience using expanded PTFE for nasal augmentation. During that time, 209 patients underwent expanded PTFE augmentation in the course of rhinoplasty at 2 academic medical centers; 52% were primary rhinoplasty candidates, and the remaining were revision cases. Implants were used predominantly for dorsal augmentation.12 The average follow-up was 40.4 months (range, 5 months to 10 years 5 months). Retrospective evaluation of charts revealed that 3.2% of grafts became infected necessitating removal. Two grafts were removed secondary to excessive augmentation, with 1 being modified and replaced. The incidence of infection was higher in those patients undergoing revision surgery (5.4% of revision surgery candidates, 3 of whom had preoperative nasal septal perforation). Grafts required removal anywhere from 1 month to 3 years, 8 months after implantation, with an average of 16 months. For most patients, expanded PTFE remains a viable option for augmentation purposes, but Godin et al12 think that its use is contraindicated in patients with nasal septal perforation; 96% of the 299 patients who did not become infected were pleased with their results.
Another argument against using autogenous cartilage concerns the remote donor site. Autogenous cartilage derived from sources other than the nasal septum creates increased morbidity in the procedure, and additional time is needed to harvest the graft. While no studies have examined patient satisfaction and outcome with regard to these additional procedures in rhinoplasty, most surgeons believe that auricular cartilage adds little to increase the morbidity of the procedure, while harvesting rib cartilage induces more postoperative pain. As previously stated, rib cartilage has additional problems with graft warpage when used improperly.
As is borne out in each of the articles that includes long-term follow-up, regardless of the type of material used for implantation, the incidence of complications decreases with increasing familiarity with operative techniques and tissue management. Overall, the number of complications in rhinoplasty should be few to none, with a high level of patient satisfaction. As has been illustrated, cartilage implants are safe, reliable, and effective. Often the results are readily reproducible. As such, the use of cartilaginous implants should be a first choice for patients undergoing primary rhinoplasty when septal cartilage is available. Septal cartilage is ideal for dorsal augmentation because it is usually straight and may be sculpted to the desired dimensions. In addition, the edges may be beveled and contoured to reduce the chance of visibility postoperatively. Auricular cartilage is also useful as grafting material in the nose with a very low incidence of complications.4 In cases of inadequate dorsal height, bilateral auricular cartilage may be harvested for grafting and carefully fashioned for augmentation in a laminated fashion. Bilayer or trilayer grafts may be placed, depending on the severity of the concavity. Familiarity with the use of auricular cartilage can lead to an excellent outcome.
In the extreme case that neither septal nor auricular cartilage is available for augmentation purposes, careful preoperative counseling with the patient should take place. Thorough analysis of the problem in conjunction with discussion regarding the need for additional tissues for augmentation purposes is imperative. Given the possibility that rib cartilage may be necessary for grafting, there is substantial added morbidity with a second harvest site. Costal cartilage sometimes warps after implantation.3 The harvest of autologous rib cartilage increases surgical morbidity, possibly requiring brief hospitalization, increased pain, and transient atelectasis. Additionally, harvesting the rib adds to the overall length of the operative time.
Based on the preceding pros and cons, the ideal implant material for maximum dorsal augmentation has yet to be identified. Dorsal augmentation seems to be the area in which expanded PTFE, as well as other alloplastic implants, are most useful. While expanded PTFE offers no structural stability, it does provide permanent augmentation and seems to be most useful in raising a low nasal dorsum. Expanded PTFE is appealing because of its availability, ease of use, and relatively low incidence of infection compared with other synthetic materials. Expanded PTFE, although approaching ideal, still has problems inherent to the implants being recognized as foreign. If the surgeon and the patient are willing to accept a 3% incidence of infection in the best-case scenario, then it is a potential material for use in the practice of the rhinoplasty surgeon.
My preference would be autologous rib cartilage, which is available in large quantities and may be contoured to fit the defect. Contouring in such a manner as to remove the outer perichondrium and leave the central portion of the cartilage may lessen the chances of warpage.7 However, in the case of dorsal augmentation where asymmetric contouring of the rib is necessary, warpage may still result.7 The data in most of these retrospective studies may be skewed because the final outcome of the patients is often unknown. Godin et al12 illustrated that infection or extrusion after implantation may take up to 3½ years when expanded PTFE is used. Patients who have lost faith in their primary surgeon may choose not to return for follow-up should a complication occur. Prospective clinical trials may enhance our understanding of the behavior of these materials.
Accepted for publication January 12, 2000.
Reprints: Jennifer Parker Porter, MD, 6550 Fannin St, Suite 1727, Houston, TX 77030-3498 (e-mail: email@example.com).
Porter JP. Grafts in Rhinoplasty: Alloplastic vs Autogenous. Arch Otolaryngol Head Neck Surg. 2000;126(4):558–561. doi:10.1001/archotol.126.4.558
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