The use of Integra™ in rhinoplasty

Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience

BACKGROUND AND OBJECTIVE

Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their 12-year experience utilizing acellular dermal matrices for nasal reconstruction.

METHODS

A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with acellular dermal matrices between 2010 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included.

RESULTS

Fifty-one patients met criteria with a median age of 77 years. Fifty-three lesions were reconstructed with acellular dermal matrices. The most common lesion location was nasal sidewall (50%) with a mean defect size of 10.8 cm 2 . 30.8% underwent same-day acellular dermal matrix reconstruction, with 69.2% undergoing two-stage reconstruction. Acellular dermal matrices successfully reconstructed acquired defects in 94.2% of lesions. Average time to re-epithelialization was 27.6 + 6.2 days. Average time to repigmentation was 145.35 + 86 days. No recurrences were recorded. Total complication rate was 9.62%. Average size for successful healing was 10.8 cm 2 . Average defect size for complication or failure was 14.7 cm 2 . Seven sites (13.46%) underwent aesthetic improvement procedures.

CONCLUSION

Acellular bilayer wound matrix is an adequate reconstructive option for single or dual-stage reconstruction of the nose with low complication and revision rates.

Frontal Sinus Displacement of Silicone Implant After Previous Rhinoplasty

Rhinoplasty, a historic surgical procedure for facial esthetics, has been actively performed in Asia. The use of autologous tissues or artificial materials, such as silicone, Gore-Tex, and Medpore, is common in achieving cosmetic improvements. However, artificial material poses risks of inflammation and foreign body reactions, leading to complications like infection and necessitating material removal and antibiotic treatment. According to previous reports, various clinical aspects appear across inflammation, skin necrosis, and, in severe cases, systemic symptoms caused by implants. In this case study, the goal is to share a rare case of silicone implant migration into the frontal sinus after augmentation rhinoplasty. A 38-year-old female patient who had previously undergone rhinoplasty surgery visited the outpatient clinic complaining of headaches and a deviated nose. On computed tomography, the silicone implant moved upward, penetrating the nasoethmoid bone and invading the frontal sinus. Fortunately, there was no intracranial invasion. The authors planned the implant removal and performed the complete implant removal with capsulectomy. The patient has been undergoing follow-up without any complications after surgery. Augmentation rhinoplasty with implants, while common, carries long-term risks. This case highlights the severity of complications, emphasizing infection and migration into the frontal sinus and, in extreme cases, the brain cavity. Therefore, surgeons must continually refine operation techniques to minimize iatrogenic causes and consider modifying surgical procedures to prevent potential complications.

Use of human acellular dermal matrix in rhinoplasty: a systematic review of the literature and meta-analysis

Alloplastic implants such as acellular dermal matrix (ADM) have been used for various aesthetic and reconstructive purposes since the 1990s. Rhinoplasty addresses both aesthetic and functional nasal impairments, often involving the adoption of grafting materials. Currently, autologous grafts, such as those using septal cartilage, are the gold standard. However, they pose the risk of donor site morbidity, technical challenges, and additional operative time. We review total complications, resorption/re-operation and success rates associated with the use of ADM in rhinoplasty. A literature search was conducted on PubMed, Prospero, DynaMed, DARE, EMBASE and COCHRANE databases. (Registry: CRD42023428019). A total of 462 patients from 15 studies were included, the mean (range) age was 30 (12-65) years, with a female-to-male ratio of 2:1. The most common indications for ADM were for cosmetic (35%, n = 163) and functional rhinoplasty (5%, n = 24). The most common type of ADM used was Alloderm (46%, n = 211). The most common indication for ADM was dorsal nasal augmentation (68%, n = 314). Eleven patients (2%) required revision surgery. The pooled success of ADM in rhinoplasty was 96% (95% CI 94 to 99, p = 0.93; I2 = 0%). 2% of patients developed postoperative complications and no statistically significant difference was seen in complications or success rates when comparing the different types of ADM. ADM in rhinoplasty was associated with fewer complications and re-operation rates, and similar if not less resorption compared to traditional autografts. Therefore, it can be a viable alternative to current autologous grafts in rhinoplasty surgery.

[Retrospective Evaluation of the Use of a Dermal Substitute in Septorhinoplasty]

BACKGROUND

At the present time, various methods exist for camouflaging the dorsum of the nose in septorhinoplasty. The subject of this paper is a retrospective descriptive evaluation of the surgical use of the bovine collagen/glycosaminoglycan matrix Integra Dermal Regeneration Template Single Layer Thin (IDRT-SL Thin) developed by Integra LifeSciences in septorhinoplasty procedures.

METHODOLOGY

The focus of this work is to evaluate the postoperative tolerability, the safety, and the course of wound healing when IDRT-SL Thin is applied as a collagen sheet in septorhinoplasty. The evaluation was performed using an evaluation form that was developed for this paper. Patients included in the study were followed up for one year postoperatively; however, the postoperative observation period considered in the evaluation was 14 weeks.

RESULTS

The analysis of the surgical results shows relatively homogeneous results for the criteria and time period we examined. No notable complications were observed within the patient cohort up to the 14th postoperative week.

DISCUSSION

Despite the limiting factors within the study due to the lack of a control group undergoing other surgical treatment procedures and the small number of patient cases, the observation period of six and 14 weeks applied in this study is suitable to determine the suitability and tolerability in principle. The results presented in this study can therefore be understood as a possible starting point for further investigations on the use of IDRT-SL Thin in septorhinoplasty.

Extensive severe intraorbital arteriovenous malformations: report of a rare laser complication and successful management

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

Technical Refinements with the Use of Biologic Healing Agents

Soft tissue defects resulting from trauma, vascular disease, burns, and postoncologic resections require reconstructive surgery for appropriate wound coverage and support. Dermal substitutes have been applied to a vast array of reconstructive settings across nearly all anatomical areas with demonstrable success. However, they require meticulous handling and operative technical expertise to optimize management of these soft tissue defects. In this review, we will address three dermal substitutes, their operative techniques, and their surgical applications.

Reconstruction of Nasal Defects With Dermal Skin Substitutes-A Retrospective Study of 36 Defects

OBJECTIVES

It is uncertain whether dermal regeneration templates (DRTs) are helpful to reconstruct nasal defects. The aim of this study was to assess whether the aesthetic subunits determine the outcome.

METHODS

In this unicentric, retrospective study, the surgical procedures and outcomes of patients who received DRTs to reconstruct nasal defects were assessed and compared with the involved aesthetic subunits.

RESULTS

DRTs were used for reconstruction of 36 nasal defects in 35 patients with involvement of 76 aesthetic subunits: nasal sidewall (n = 21), nasal ala (n = 13), nasal tip/columella (n = 12, n = 1, respectively), nasal dorsum (n = 12), and extranasal aesthetic areas (n = 17). Fifty-eight nasal and 8 extranasal aesthetic subunits were reconstructed with DRTs, 10 subunits with a flap. Twenty-nine of 36 defects healed without any complications (80.5%). All reconstructed nasal tips/columella and the nasal dorsa healed without any complications. Region-specific complications were retraction of the ala rim (4/12; 33.3% of the patients with involvement of the nasal ala) and the formation of a fistula in the nasal sidewall (1/21; 4.8%). Region-specific complications of extranasal subunits were the development of an ectropium (2/3; 66.7% of the patients with involvement of the lower lid).

CONCLUSIONS

DRTs can be helpful to reconstruct nasal defects. However, if the defect involves the aesthetic subunits nasal ala or the infraorbital region, different techniques should be preferred.

In vivo evaluation of a regenerative approach to nasal dorsum augmentation with a polycaprolactone-based implant

Background

Alternative techniques for nasal dorsum augmentation are of paramount importance in reconstructive and plastic surgery. In contrast to autologous cartilage grafts, tissue-engineered grafts can be created de novo and yield low–none donor site morbidity as compared to autologous grafts like rib or ear cartilage. To address this demand, this study investigated the in vivo regenerative potential of polycaprolactone-based implants as an alternative to autologous cartilage grafting during rhinoplasty.

Methods

Implants were placed at the nasal dorsum in two groups of minipigs and kept in situ for 2 and 6 months, respectively. Subsequently, the implants were harvested and examined by histology (hematoxylin–eosin, alcian blue, and safranin O) and immunostaining (collagen I and collagen II). Further analysis was performed to measure diameter and distance of polycaprolactone struts.

Results

Histological examination revealed a persistent formation of connective tissue with some spots resembling a cartilaginous-like matrix after 6 months. In such areas, cells of chondrocyte appearance could be identified. There was a significant decrease in strut diameter but a non-significant difference in strut distance.

Conclusion

Our results indicated that the investigated polycaprolactone-based implants have shown a regenerative and stable nasal dorsum augmentation after 6 months in vivo. Thus, we believe that customized polycaprolactone-based implants could become an alternative technique for nasal dorsum augmentation without the need for autologous cartilage grafts.

The Use of Double-Layer Collagen Membrane for the Improvement of Nasal Dorsum Skin Thickness and Texture in Primary Nose Surgery

OBJECTIVES

To place a collagen membrane containing crushed nasal septal cartilage over the nasal dorsum to see how this graft can improve the results of visible postsurgical irregularities in thin skinned patients.

METHODS

Fifty-seven patients were treated between 2006 and 2010 (26 males and 31 females) whose ages ranged between 31 and 55 years old. They were divided into group a, defect <1 mm, group b defect between 1 and 2 mm, group c defect >3 mm. These patients presented intraoperative nasal dorsum irregularities that were corrected with 57 cartilage grafts in conjunction with collagen membrane.

RESULTS

All of our patients showed an initial over-correction. A dense network of collagen fiber bundles was observed running parallel to the surface of the membrane at the connective tissue-membrane interface. The clinical percentage of volume reabsorption was about 5% after 6 months, measured with clinical pictures and a clinical follow-up. No infection was noted, only 1 patient of dislocation was observed, and 5 patients required some refinements at the long-term follow-up.

CONCLUSIONS

In the authors' experience the use of bilayered combined cartilage and collagen membrane grafts gives the best aesthetic results with balanced tip projection and dorsum fullness, and avoids thickness and texture modification of the skin above the graft. The use of Bio-gide membrane avoids all problems related to the donor site and shortens surgical time.

Nonsurgical Rhinoplasty with Injectable Fillers: Italian Technique for Reshaping the Tip of the Nose

Introduction:

The rhino filler is a relatively recent complementary technique to rhinoplasty. The filler provides good results in certain selected cases, camouflaging irregularities of the dorsum and tip. This study aims to evaluate the Italian technique for the modification of the tip, a seemingly trivial but very effective technique. In selected cases, it is possible to successfully modify the tip of the nose using a simple double injection of filler within a few seconds.

Materials and Methods:

A total of 212 subjects were treated with filler in a single session. The patients were carefully selected, and each presented to varying degrees and in different ways with the tip of the nose projected and/or turned downward. The goal of the treatment is to provide greater projection and an upward lift of the tip. Follow-up visits evaluated the result, degree of patient satisfaction, and adverse reactions.

Results:

Of the patients, 79.2% claimed to be completely satisfied, 11.3% moderately satisfied, and 9.5% had no observable improvement. When evaluated photographically, 92.4% demonstrated improvement.

Discussion:

The technique has inherent limitations. It cannot change the structure of bone or cartilage, and it can correct only with an increase. For this reason, it is essential to select patients carefully. This study reported no major adverse events, and this is encouraging.

Conclusions:

This technique standardizes the reshaping of the tip with injectable fillers, reducing the number of injections to 2 boluses, by becoming a safer treatment, easier carrying, quick, well tolerated, economical, durable, and with maximum results.

Regenerative medicine and nasal surgery

Nasal surgery is a constellation of operations that are intended to restore form and function to the nose. The amount of augmentation required for a given case is a delicate interplay between patient aesthetic desires and corrective measures taken for optimal nasal airflow. Traditional surgical techniques make use of autologous donor tissue or implanted alloplastic materials to restore nasal deficits. Limited availability of donor tissue and associated harvest site morbidity have pushed surgeons and researchers to investigate methods to bioengineer nasal tissues. For this article, we conducted a review of the literature on regenerative medicine as it pertains to nasal surgery. PubMed was searched for articles dating from January 1, 1994, through August 1, 2014. Journal articles with a focus on regenerative medicine and nasal tissue engineering are included in this review. Our search found that the greatest advancements have been in the fields of mucosal and cartilage regeneration, with a growing body of literature to attest to its promise. With recent advances in bioscaffold fabrication, bioengineered cartilage quality, and mucosal regeneration, the transition from comparative animal models to more expansive human studies is imminent. Each of these advancements has exciting implications for treating patients with increased efficacy, safety, and satisfaction.

Ultrasonographic monitoring of new expanded polytetrafluoroethylene implant thickness after augmentation rhinoplasty

BACKGROUND

Expanded polytetrafluoroethylene (e-PTFE) is currently one of the most popular implant materials for rhinoplasty. Surgiform (Surgiform Technology, Ltd., Lugoff, SC) is a recently introduced ePTFE material with physical characteristics that are slightly different from Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ). Changes in Surgiform thickness after rhinoplasty are not well documented.

METHODS

This prospective study enrolled 16 patients (12 male and 4 female patients) who underwent primary augmentation rhinoplasty with Surgiform. High-resolution ultrasonography was used to measure implant thickness after a mean follow-up period of 14.7 months (range, 8-21 months).

RESULTS

Surgiform implants were easily and clearly demarcated from surrounding tissue. The mean thickness of inserted implants was 2.37 ± 0.80 mm at the rhinion and 3.12 ± 1.26 mm at the supratip. The follow-up thickness was 2.35 ± 0.77 mm at the rhinion and 3.09 ± 1.23 mm at the supratip. Implant thickness did not decrease significantly at the rhinion (p = 0.112) or the supratip (p = 0.165).

CONCLUSION

Ultrasonographic monitoring indicated that Surgiform e-PTFE does not shrink significantly over time.

Complications of injectable fillers, part I

Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.

Soft versus hard implants in dorsal nasal augmentation: a comparative clinical study

BACKGROUND

Dorsal nasal augmentation plays an important role in cosmetic and reconstructive rhinoplasties performed to achieve an aesthetically pleasing result while creating facial harmony. Although it is known that the ideal implant should be biocompatible, biointegrated, nonabsorbable, and without inflammatory response, the selection of an ideal implant still remains controversial as to whether it should be biologic or synthetic. This study introduces a new question: ''What is better for the nasal dorsum, a soft or a hard implant?''.

METHODS

In this study, 21 women and 7 men with a mean age of 23.5 years underwent augmentation rhinoplasty between December 2007 and July 2011. Conchal and septal cartilage grafts and Medpor were categorized as hard implants and applied for 15 patients. Soft implants, inserted in 13 patients, included diced auricular cartilage wrapped in Surgicel sheets, dermofat blocks, and rolls of Prolene mesh.

RESULTS

Patient satisfaction was assessed through simple postoperative questionnaires. The satisfaction rate in the soft implant group was 100 %, whereas the overall satisfaction rate was 82.2 %. Unsatisfactory results and complications were recorded in the hard implant group, which had a dissatisfaction rate of 33.3 %, contributing to a general dissatisfaction rate of 17.8 % in the whole series.

CONCLUSION

The authors recommend soft implants for both aesthetic and reconstructive surgeries because of their better ability to achieve a dorsum with a smoother contour and pad. Soft implants have fewer complications and higher satisfaction rates and can be applied for most indications using both closed and open methods.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article.