Management of the Nose After Rhinoplasty: Techniques, Outcomes, and Complications
Most intervention regarding the nasal dorsum, or the nose's external ridge, involves either augmentation, in cases of deficiency, or reduction, in the presence of an existing hump. Augmentation is generally performed to fortify the nasal dorsum and smoothen bumpiness. Authors have published a plethora of techniques using a broad array of tissues and implants.
Autogenous & Homologous Tissue
Autogenous Cartilage
Although a multitude of options exist for augmentation of the nasal dorsum, it appears that autogenous cartilage is likely the preferred method. Autogenous cartilage is simply cartilage without a filler. There are many available options for primary rhinoplasty, but options may be limited in revision surgery. Cartilage can be harvested from a variety of areas using ear, septal, costal, and the upper or lower lateral cartilages. There exists no consensus regarding the preferred donor site when all are available, although utilization of septal cartilage avoids the need for a second wound. Warping and migration were found to be problems in some patients who received costal cartilage grafts from their ribs. Graft resorption, infection, and revision rates are comparable, regardless of the donor cartilage used. Furthermore, in some cases diced cartilage is used. The techniques implemented for graft insertion possess substantial variation.
Complications from the use of autogenous cartilage includ infection (1.5-5%), implant migration (1-12.5%), resorption (0.5-5%), and warping (2.5-5%).
Homologous Cartilage
Complications from the use of foreign cartilage included infection (0.87-7.4%), resorption (1-7.4%), displacement (0.3-5.9%), warping (1-14.8%), and exposure (3.6%).
Bone
Although cartilage is the preferred tissue for dorsal augmentation, multiple surgeons have described the use of bone as well. Bone was commonly used for moderate or greater dorsal defects.
Complications included extrusion (3.4-6.3%), infection (1.9-5%), resorption (4-49%), and displacement (1.9-3.6%).
Soft Tissue
Other surgeons have suggested the use of dermal grafts and superficial muscular tissue for the purpose of dorsal augmentation. The results of both revealed high patient satisfaction, with the most common complication being underaugmentation. The use of cadaveric dermis, self-generated fat, and fibrofatty tissue grafts were reported to have acceptable results. Of note, soft tissue was used primarily as a tool for augmentation in mild to moderate dorsal depression and/or contour defects. There were no reports of extrusion, infection, or displacement.
Synthetic Implants
Synthetic implants in rhinoplasty have been the topic of great controversy. Introduction of a foreign body and the ensuing inflammatory changes to such unforgiving anatomy is of great concern.
Silicone
The use of silicone in rhinoplasty is a point of worldwide contention among plastic surgeons. Perhaps the difference in opinion on whether or not this is a valid option stems from what some surgeons deem acceptable risk and others do not. Albeit small according to the literature reviewed, there does exist the risk of implant extrusion and subsequent skin loss. Combined with the risk of local infection, it appears prudent to state that introducing silicone for the purposes of dorsal augmentation should be used in only the most careful manner.
Complications reported included extrusion (2.1-3.7%), infection (3.7%), and displacement (3%). Several authors found graft dislocation to be a primary concern.
Expanded Polytetrafluoroethylene (Gore-Tex)
Gore-Tex should also be used with caution. Although the extrusion rates appear to be lower, there still exists the potential for complications related to this foreign body. As Gore-Tex is a foreign body that is placed in close proximity to the nasal cavity, which has a naturally high bacterial load, it may be more susceptible to infection. This is a logical explanation for the observed complication of extrusion. However, further studies are needed to further assess the cause of this issue. The rate of infection in Gore-Tex appears comparable to that of silicone after systematic review.
Complications included extrusion (1%) and infection (1-3.2%). Several studies noted a higher complication rate in those patients undergoing revision surgery, urging caution in this subset. Several studies also reported acceptable results when Gore-Tex was used in combination with cartilage grafts.
High-Density Polyethylene (Medpor) and Polyethylene Terephthalate (Dacron)
Complications included extrusion (3.1-10.7%) and infection (1-6.25%). Several authors noted patient complaints of local firmness and numbness.
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