As a conservative surgeon, I believe in creating natural-appearing, well-supported, well-balanced noses. As a result, I not infrequently find the need to add something to create projection, balance, or support. Like everyone else, I try to use auto-logous septal cartilage wherever possible. There have been times, however, when there just wasn’t enough septum to do the job. So I have turned, on occasion, to the use of implants. When academics present at meetings, or write about the successful experience they’ve had with a new implant material, I am likely to give it a try if it seems to be safe, and sensible, and if their numbers are good. Upon reviewing my own experience, I am glad I took their advice less than half the time, so for me this is a time to reassess this question, and I invite the reader to do the same.

Notwithstanding the fact that every article ever written about nasal reconstruction indicates that autologous grafts are superior, all the available alternatives, as well as those used not so long ago, which are no longer available, are outlined in Table 33-1.

Literature Experience

GRAFTS

In the most recent comprehensive treatment of the subject of grafts and implants in rhinoplasty, Maas et al.¹ state that “auto-graft cartilage is the most commonly used material in rhino-plasty and remains the standard against which all others are compared.” There is no disagreement with this statement among experts. When used to augment or support the nose, autogenous cartilage has proved to provide long-lasting clinical correction and to be very resistant to infection or extrusion.² Tardy³ reports more than 6000 cartilage autografts implanted over 25 years, with no incidence of rejection or infection: “infrequent complications p have stemmed from technical errors that diminish with experience p. No significant complications have occurred from the inherent unique properties of the cartilage autograft itself.” The issue of the technical errors is an important one. Sheen and Tardy spend considerable space discussing technical considerations to ensure adequate blood supply, and avoidance of malposition and visibility, the two most common problems with autografts. I shall return to this issue later.

Typically, articles that tout the use of one or another implant report complication rates of less than 5%.4–6 Reports of complications often come from other investigators, citing their own experience with implants inserted by other surgeons. I especially like the wording of a Chinese article that analyzes 349 complications (how much is enough?) of dorsal augmentation using ersatz materials.⁷ Tardy says it very well: “The continuing opportunity to care for referred patients suffering from the unpleasant results of nasal implant rejection influences significantly a philosophy of conservatism and patient safety above all else.”

Things change pretty quickly on the nasal implant scene. A comparison of two excellent review articles published only 10 years apart points this up very well. A well researched review article in 1987 by Adams⁸ can be compared with similarly scholarly reviews by Kridel and Kraus⁹ and Maas et al.¹ in 1995 and 1997, respectively. Table 33-2 divides the critiques of these materials into two categories: Then and Now.

Although little, if any, harm has been done by properly performed liquid silicone injections, much legal hay has been made of this substance. Is there an alloplast that is immune from suddenly being declared illegal at some point in time, putting both the manufacturer and the practitioner at great risk?

What about the fact that we continue to use Silastic implants in the nose, even though it is well documented that “in nasal augmentation its use is limited. Thin soft tissue coverage, constant movement of the nose, and frequent midface trauma lead to an unacceptably large incidence of dislodgment and extrusion.”⁸

MERSILENE MESH

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