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Alloplastic materials are well suited for use in rhinoplasty in the right clinical scenarios, specifically in patients with platyrrhine noses and in challenging revision cases. The most commonly used materials today are silicone and high-density porous polyethylene. Both implant materials carry a unique set of properties and offer various advantages and disadvantages for use. Complications can be minimized with appropriate utilization of implants and using proper technique., Competing Interests: Disclosures No disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Vascular compromise leading to cutaneous loss following surgical rhinoplasty is a devastating complication. The objective of this review is to identify all reported cases in literature published in English and summarize the current evidence to identify the patients at risk of this complication following surgery. A comprehensive literature review using Medline and Embase databases was performed to capture all reported cases of cutaneous vascular compromise following rhinoplasty from database inception through September 2020. Nonsurgical rhinoplasty cases were excluded. We identified eight studies that featured vascular cutaneous compromise following surgical rhinoplasty. A total of 18 patients were included in the analysis. The majority of the patients were females with a mean age of 30.9. Risk factors included smoking in 23.5% patients and revision setting. Extensive tip thinning, tight splinting and taping with dorsal onlay grafting, or combining extended alar base excision with revision open rhinoplasty were among surgical techniques associated with vascular compromise. The most commonly affected aesthetic nasal subunit in our review was the dorsum followed by the nasal tip. Conservative management primarily was utilized in 72.2% of patients, allowing the defect to heal by secondary intention. Studies reporting on cutaneous vascular compromise following surgical rhinoplasty are of low level of evidence. This review is the largest summary reporting on this complication to date, aiming to caution surgeons about associated techniques and management options. We also share an expert opinion on preoperative assessment of nasal skin to guide surgeons to potentially avoid rhinoplasty surgery in this subset of patients., Competing Interests: None declared., (Thieme. All rights reserved.)

In this article, options for nasal implantation during rhinoplasty are discussed. The range of implant options currently available to the nasal surgeon is considered in detail. Various types of autografts, homografts, and alloplasts commonly used in the nose are introduced and described. Indications for each nasal implant type are considered, as are the advantages and limitations of each option.

This article reviews the case of a 45-year-old female who had undergone previous rhinoplasty in which there had been overaggressive resection of the nasal skeletal architecture. A revision rhinoplasty was preformed using available autogenous septal cartilage and various porous high-density polyethylene implants. One year after the procedure, the patient demonstrated restoration of nasal architecture and persistent aesthetic outcomes.

Background: This study aimed to evaluate a surgical technique used for patients requiring revision rhinoplasty to reestablish their ethnic identity., Methods: A retrospective review involved 29 patients who underwent revision rhinoplasty to reestablish their ethnic identity using residual septal cartilage and porous polyethylene implants. The follow-up period ranged from 6 month to 7 years., Results: For all patients undergoing revision rhinoplasty, multiple porous polyethylene implants were used to reestablish ethnic identity and to restore nasal function. Implant extrusion developed in one (3.4%) of the 29 patients. There were no cases of postimplant infection., Conclusions: In our experience, patients who feel they have lost their ethnic identity after primary rhinoplasty tend to have overresected dorsal cartilage and bone and overresected tip cartilages. The use of multiple porous polyethylene implants in revision rhinoplasty to restore ethnic identity can provide the necessary grafting material needed for reconstruction. Many grafting options are available. According to our experience, porous polyethylene provides safe, effective, and reliable results.

Problems associated with primary rhinoplasty are often due to overresection of the nasal skeleton. One of the primary goals in revision rhinoplasty is to restore nasal architecture. To do so, the facial plastic surgeon can choose from numerous grafting materials. A key understanding of the benefits and limitations of each implant or graft and implants commonly used in revision rhinoplasty surgery.

The reduction structured rhinoplasty has evolved based on an increased understanding of nasal function and structural anatomy. The discussion begins with the philosophic origins of this technique. Next, the preoperative visit is outlined including the history, physical examination, basic facial analysis, and surgical planning. The procedure is detailed and the postoperative care is described.

Background: It is accepted in rhinoplasty that complications are more common with alloplastic implants than with autografts. There is little guidance in the literature on how to deal with the cosmetic and/or functional problems that follow alloplastic implant rejection. The conventional advice has been to remove the allograft and not place any graft at the same time. The present article presents our experience treating allograft rejection and immediately repairing any structural defect with autografts., Objective: To demonstrate that immediate nasal reconstruction using autogenous cartilage is a good technique when an alloplastic material has to be removed because of rejection, inflammation, or infection., Design: A retrospective analysis of outcome for a case series., Methods: A retrospective review of the management of 8 patients who presented to 2 tertiary referral centers with alloplastic implant rejection following rhinoplasty. In 7 cases, the alloplastic implant had to be removed because it had migrated and caused a foreign body reaction; in 1 case, the implant had caused a bacterial infection., Results: In all 8 cases, the nasal deformity that followed the removal of the allograft was so marked that the nose was immediately reconstructed with autogenous cartilage. The patients all made a good recovery after immediate reconstruction, although skin changes associated with the alloplastic implant remained after a mean follow-up of 3 years 3 months., Conclusion: The use of autogenous cartilage is a good option for nasal augmentation immediately after the removal of an alloplastic implant.

The aging nose presents a difficult challenge for the rhinoplastic surgeon. To best address the patient's wishes, the surgeon must possess a sound understanding of the atrophic changes associated with the aging nose, including tip ptosis, increased nasal bulbosity, a lengthened nasal appearance, and altered nasal airflow patterns. Surgical emphasis is placed on conservative structured reduction to address functional concerns. Overresection risks destabilizing the nasal tip and altering the patient's concrete self-image. This article outlines our approach to rhinoplasty in the aging nose with a special emphasis on the use of porous polyethylene alloimplants to provide added structural support.

Rhinoplasty entails several steps that affect the appearance and function of the nose in an interrelated way. Occasionally, an excellent result can be marred by a minor imperfection and lead to dissatisfaction of both patient and surgeon. For significant pathology, revision rhinoplasty can be performed safely if the architecture and physiology of the nose are respected. To correct the "near-miss" result, minor corrections can successfully restore the aesthetic result. This can require a different frame of reference and approach and can often be thought of in terms of soft tissue correction. Subcutaneous fibrosis, skin depressions, asymmetries, and deficits can be corrected with minor procedures and techniques not routinely associated with rhinoplasty. We detail several methods that can be used to restore simply and effectively an otherwise excellent rhinoplasty result.

Reliable outcomes in correction of the severely bulbous nasal tip remain elusive. Reduction and binding of the tip cartilages result in a partial external nasal valve collapse. If a concurrent dorsal hump reduction is accomplished and osteotomies are completed to close the open roof deformity, then a severe constriction of the external valve may result. This is best avoided by resection of the residual lower lateral cartilages and substitution with external valve batten implants. The tripod of nasal tip supports is then rigidly reconstituted. When autogenous graft materials are considered inadequate or undesirable, the surgeon may safely use porous polyethylene alloimplants to support the external nasal valve. A dependable surgical technique based on extensive experience with these materials is outlined.

Rhinoplastic surgeons continue to seek technical refinements that will result in a consistently reliable postoperative outcome. Over the past 25 years there has been a steady progression away from the simple Joseph reductive rhinoplasty technique toward the use of various grafts to improve both the functional outcomes and aesthetic end result of this procedure. The original reductive template continues to be a major component of a new conceptual paradigm, which has evolved to incorporate the understanding that structural components must be placed to allow a more precise outcome. Specifically, once the nose is reduced to proportions that correspond to the preoperative analysis, separate grafts and implants are placed to prevent a change in the shape of the nose by the constricting effects of the skin shrink-wrapping around the skeletal framework. This article focuses on the use of implants for structural architecture in the senior author's primary reduction-structured rhinoplasty cases.

Secondary nasal deformity associated with cleft lip is a difficult surgical task. For more than 100 years, numerous surgical methods have been created to address the structural changes that occur over time after the primary surgery. Although early surgical methods have relied on various rotational flaps and local tissue manipulation, the recent advent of synthetic materials has provided facial plastic surgeons with more tools to correct the structural and supportive deficiencies. In this article, we describe our 10-year experience with porous high-density polyethylene (PHDPE) implants in secondary cleft-lip rhinoplasty. PHDPE implants have been well tolerated and achieved excellent long-term aesthetic results through fibrovascular ingrowth to the surrounding tissue.

Revision rhinoplasty can be one of the most complicated procedures performed by the facial plastic surgeon. As septal cartilage is often not available in revision procedures, grafting material is often needed. This material can come in the form of autogenous bone and cartilage. Allografts also can be used, including mersilene, expanded polytetrafluoroethylene, and porous high-density polyethylene (PHDPE). In this article, emphasis is placed on the senior author's method in evaluating candidates for revision rhinoplasty as well as techniques using PHDPE. In addition, the properties of the more commonly used allografts are described, including the advantages and disadvantages of using each material in revision rhinoplasty procedures. In comparing the various alloplastic materials available, it is shown that PHDPE has properties that make it an excellent implant for revision rhinoplasty.

Background: The multitude of factors involved with a unilateral cleft lip nasal defect has spurred various surgical techniques in the past. Recently, synthetic materials have been introduced for use in nasal reconstruction., Objective: To report on and illustrate the use of porous high-density polyethylene implants in cleft lip nasal reconstruction., Design: A retrospective review of cleft lip nasal reconstruction using porous high-density polyethylene in patients with a unilateral cleft lip defect from January 1, 1993, through June 30, 2000., Setting: Facial plastic surgery private practice., Patients: Eighteen patients with a unilateral cleft lip without a history of formal rhinoplasty., Interventions: All 18 patients required multiple implants, including a columellar strut, premaxillary and prealveolar plumper grafts, a dorsal tip implant, and a unilateral nasal valve batten, using the open rhinoplasty approach., Results: Favorable aesthetic results, as judged by one of us (T.R.), were achieved in all patients. All implants were well tolerated. Postoperative follow-up ranged from 6 months to 7 years. A complication occurred in 1 patient (6%), which resolved with removal of a single implant and intravenous antibiotic therapy. No other complications, including skin erosion or implant extrusion, have been noted., Conclusions: Porous high-density polyethylene implants for cleft lip nasal reconstruction are well tolerated and achieve good aesthetic results. Porous high-density polyethylene implants lend stability through fibrovascular ingrowth, with integration of the implants to the surrounding tissue.

The development of a deforming nasal-dorsal mass after rhinoplasty is a very rare and, for the most part, an avoidable complication. The list of differential diagnoses for such a postoperative external nasal lesion ranges from simple soft tissue edema or hematoma, which is usually temporary, to more serious lesions, such as lipogranulomas, epidermoid inclusion cysts, tumefactive cartilage proliferation, and mucous cysts, which can cause permanent deformities. Although various nasal tumors, infections, and granulomatous diseases are not specifically related to surgery, they should also be considered.

Nasal reconstruction presents a significant challenge to the facial plastic surgeon. Reestablishment of the desired aesthetic nasal contour and restoration of respiratory function are the dual goals of this endeavor. While autologous cartilage or bone is considered optimal grafting material, the supply is often limited and harvesting entails additional morbidity. Many synthetic materials have been introduced for use in nasal reconstruction, but high infection and extrusion rates have left most surgeons dissatisfied with conventional implants. Porous polyethylene (Medpor) implants were used for nasal reconstruction in 187 patients; 66 (35.3%) patients underwent primary rhinoplasty, while revision surgery was performed in 121 (64.7%) patients. Most patients required multiple implants, including columella struts, plumper grafts, dorsal tip implants, and nasal valve battens. Postoperative follow-up ranged from 6 months to 3.5 years. Complications occurred in five (2.6%) patients. Three early and two delayed infections necessitated implant removal in five patients, all of whom had compromised skin-soft tissue envelopes secondary to heavy smoking, cocaine abuse, or prior surgery. One case of an overly augmented nasal dorsum and tip required implant removal, reduction, and reinsertion. All implants were easily removed. No other complications including implant extrusion or skin erosion have been noted. Porous polyethylene (Medpor) implants allow for fibrovascular ingrowth, which lends stability to the implant. Porous polyethylene implants are well tolerated and provide an ideal material for nasal reconstruction.

The major saddle nose deformity leaves a patient with an obvious aesthetic deficit as well as an equally disturbing functional handicap. Reconstructing the collapsed dorsum and tip and simultaneously restoring nasal function present a formidable challenge which has elicited a wide variety of solutions ranging from the use of a toothbrush handle to split calvarial grafting. As Murakami et al pointed out, the "variability exists to a large extent, because the saddle nose deformity is not a single entity but rather a spectrum of abnormalities." Attempts to categorize saddle nose deformities are useful; however, they often lack the simple impact and clarity of the pre-operative photograph. Moreover, the categorizations have not led to a uniform approach to this complicated problem. Nevertheless, Tardy's classification of minimal, moderate, and major saddle nose deformities provides a helpful framework for discussion of reconstructive options. Minimal deformities demonstrate a supratip depression of 1 to 2 mm and are easily corrected with cartilage or fascial overlays. Moderate saddle nose deformities are characterized by a significant loss of dorsal height as well as columellar retraction and broadening of the bony pyramid. A major deformity demonstrates "all of the stigmata of the moderately saddled nose, only to a more marked degree." In Tardy's opinion, an open approach may be warranted in these cases. We offer one solution to the major saddle nose deformity using a composite allo-implant of porous high-density polyethylene (PHDPE) (Medpor surgical implants, Porex Surgical, Inc., College Park, GA) and purified acellular human dermal graft (Alloderm, Life Cell Corp., TX.). While we readily admit that autogenous tissue is the preferred grafting material, we have encountered patients in whom this is not an option. Major saddle nose deformities typically require more augmentation than stacked septal or auricular cartilage can provide. Additionally, in patients seeking revision rhinoplasty, sufficient donor septal or auricular cartilage is often lacking. Resorption of irradiated cadaveric rib grafts has led us away from this material. Split calvarial bone grafts are our next recommendation for these patients; however, many patients refuse this option. In these patients we have turned to a composite allo-implant of PHDPE and acellular human dermal graft for reconstruction of the collapsed dorsum and tip.

The reconstruction of nasal deformities after trauma or surgical procedures presents an arduous task for the reconstructive surgeon. The anatomic alteration of supporting cartilage and nasal bones, as well as scar formation, compound the difficult nature of this type of reconstruction. In the past, multiple autogenous and alloplastic implants have been used in nasal reconstruction. Autogenous implants include auricular and septal cartilage as well as rib and iliac crest bone grafts. Alloplastic materials include acrylic, supramid mesh, Gortex, and silicone rubber. Autogenous grafts have been shown to provide excellent long-term reliable results in nasal reconstruction. In our study, autogenous split calvarial bone grafts were used in the nasal reconstruction of 17 patients. Among the corrective procedures were dorsal augmentation for saddle-nose deformities, insertion of columella struts for nasal tip ptosis, and insertion of nasal battens for nasal valve collapse. Patient followup has been from 1 to 5 years, with no significant resorption noted during that time. Complications were limited to one seroma at the donor site before wound drains were routinely used. No major complications, including hematoma formation, CSF leak, or infection, have been observed.

The platyrrhine nose is characterized by a hypoplastic nonprojected nasal tip, wide flaring alae, underdeveloped premaxilla, and lack of nasal dorsal support. Aesthetic nasal reconstruction is performed utilizing the external rhinoplasty technique. Precise placement of nasal augmentation grafts is facilitated by this technique. The harvesting and utilization of a large autogenous nasal fibrofatty graft for finesse dorsal contouring is described. Seventy-five patients underwent aesthetic reconstruction of the platyrrhine nose. Follow-up ranged from 2 to 7 years. No major complications, including extrusion or significant resorption of augmentation grafts, have been observed. Minor complications included notching of the transverse columella incision in 5% (4/75) of cases, observable suture tract marks along the alar closure incision in 4% (3/75) of cases, and alar incision granuloma in 1% (1/75). A modification of our technique, utilizing a two-layer tension-free closure of the columella and alar incisions, has alleviated these complications.