The complications of giant titanium implants in nasal reconstruction

Promising Implants in Rhinoplasty

Many dilemmas in rhinoplasty tempt surgeons to use exogenous materials. We have long looked toward implants to decrease operative time, to achieve a more reliable result, or when there is a paucity of autologous material. More than ever, the innovative and highly lucrative field of nasal implantology is developing technologically advanced products. This article looks at some popular nasal implant choices with a look toward what might be on the horizon.

[Secondary facial recontouring with micro-porous titanium implants]

Facial recontouring has always been a longstanding objective of esthetic or reconstructive surgery. Most often it uses two types of surgical techniques: autologous and alloplastic. In that regard, different surgical techniques have been proposed to enhance facial recontouring.

MATERIALS AND METHODS

Through 5 clinical case reports and a literature review, this article explores the use of allopastic microporous titanium implants in secondary volumetric corrections of the face.

RESULTS

There is a current lack of evidence regarding the use of microporous titanium implants in volumetric corrections of the face, most papers reporting their use in post-traumatic or post-surgical cranio-facial defects repair.

DISCUSSION

Pros and cons of such implants are discussed in association with the usefulness of this surgical technique in daily surgical practice.

Primary human nasal epithelial cell response to titanium surface with a nanonetwork structure in nasal implant applications

In nasal reconstruction applications, the response of cells to titanium (Ti) implants is largely determined by the surface characteristics of the implant. This study investigated an electrochemical anodization surface treatment intended to improve the response of primary human nasal epithelial cells (HNEpC) to Ti surfaces in nasal implant applications. We used a simple and fast electrochemical anodization treatment, i.e., applying anodic current, to produce a titanium dioxide (TiO2) nanonetwork layer on the Ti surface with average lateral pore size below 100 nm, depending on the current applied. The TiO2 nanonetwork layer exhibited enhanced hydrophilicity and protein adsorption ability compared with untreated Ti surfaces. In addition, the spreading morphology, cytoskeletal arrangement, and proliferation of HNEpC on the nanonetwork layer indicated excellent cell response characteristics. This research advances our understanding regarding the means by which a TiO2 nanonetwork layer can improve the response of HNEpC to Ti surfaces in nasal implant applications.

[Total nasal reconstruction with a titanium miniplate as structural support]

INTRODUCTION

Total nasal reconstructions using bone graft, as structural support is the gold standard. We retrospectively studied an alternative technique relying on a titanium miniplate as a structural support.

PATIENTS AND METHODS

Five patients underwent total nasal reconstruction, using a 1mm titanium miniplate fixed to the frontal bone and to the anterior maxilla. The miniplate was covered by a fascia lata graft in three cases. The functional and aesthetic results were evaluated on a scale from 0 (disappointing results) to 3 (excellent results) by the patient and by the surgeon, at 1 month and at 3 years after the total nasal reconstruction.

RESULTS

The functional results were assessed on average at 2.2/3 at 1 month, and 2.4/3 at 3 years postoperatively. The aesthetic results are estimated at 2 (patient) and 1.8 (medical team) at 1 month and at 2.6 (patient) and 2.2 (medical team) at 3 years. There were no major complications. The minor complications were exposure of the two miniplates, which had not been covered with fascia lata. These complications were resolved by local surgery.

DISCUSSION

The functional and aesthetic results of total nasal reconstruction relying on a titanium miniplate were similar to those obtained with a bone graft. This technique is simple, there is no need for an osseous donor site, it is stable at long-term, and its cost is moderate.

Three-dimensional virtual technology in reconstruction of mandibular defect including condyle using double-barrel vascularized fibula flap

OBJECTIVE

The aim of this study is to demonstrate the reconstruction of mandibular defects including the condyle using a double-barrel vascularized fibula flap aided by three-dimensional virtual technology.

METHODS

Ten patients with the type H mandibular defects, who had undergone mandibular reconstruction using a double-barrel vascularized fibula flap, were reviewed for this study. Prior to the surgery, the patients CT scan data were analyzed virtually using SimPlant Pro™ software (version 11.04). The simulation allowed construction of an individual mandibular model serving to guide the clinical operation.

RESULTS

The preoperative virtual surgery greatly benefitted the actual surgery. The vertical height of the neomandible and facial contour were precisely predicted. Some minor complications were encountered. Postoperative three-dimensional reconstruction revealed a close match with the simulated condyle.

CONCLUSION

A double-barrel vascularized fibula flap can provide sufficient bone, both in length and vertical height, for the reconstruction of a type H mandibular condylar defect. Combined virtual three-dimensional reconstruction and rapid prototyping can improve postoperative outcomes in mandibular reconstruction.

Management of composite defects of the nose, cheek, eyelids and upper lip

AIM

To assess the results of reconstruction of composite defects involving the nose which extend to involve the cheeks, eyelids or upper lip.

STUDY DESIGN

Retrospective observational study.

MATERIAL

Sixteen patients with defects of the nose extending to the adjoining cheek, upper lip or eyelid.

METHOD

A combination of flaps and grafts were needed to reconstruct these defects so that the aesthetic subunits were replaced and joined at their junctions wherever possible.

RESULTS

Where the defect required three or four flaps, there was some unpredictable cicatrisation at their junction that resulted in some asymmetry. This problem primarily occurred at the alar base, and was compounded if there was tissue loss of the premaxilla or maxilla.

CONCLUSION

If a defect that involves the nose, cheek and upper lip is repaired with a combination of cheek advancement, nasolabial, paramedian forehead and/or septal flaps, there can be unpredictable cicatrisation at their junction, particularly at the alar base. In these circumstances, we recommend replacing the nasal and other defects with a slightly more generous amount of tissue than would be taken to repair a similar, but solitary, defect. It is important to replace any loss of the facial skeleton, in order to provide support for overlying flaps.

Partial nasal reconstruction with titanium mesh: report of five cases

The nasal pyramid is frequently affected by nonmelanoma skin cancer. Sometimes the aggressiveness of tumours entails the extirpation of the mucosa, the cartilage, and the nasal skin. Reconstruction of the cartilaginous portion can be a surgical challenge. We demonstrate that titanium mesh can be an effective substitute for the cartilaginous portion of the nose in nasal reconstruction. We present five patients with nasal basal cell carcinoma who were treated by Mohs micrographic surgery. The partial loss of the cartilaginous structure was replaced by a 0.1 mm fenestrated titanium mesh. We have not observed any rejection or other complication in any of our patients. Good functional and aesthetic results have been obtained. Because of its biocompatibility, titanium mesh is a useful substitute for nasal cartilage. It avoids harvesting natural cartilage, reduces the risk of graft necrosis, and prevents morbidity in the donor area.

The use of alloplastic materials in rhinoplasty surgery: a meta-analysis

BACKGROUND

Conventional wisdom regarding the use of alloplastic materials in rhinoplastic surgery would advise against their use because of safety and aesthetic concerns. However, autogenous tissue harvest is not without associated morbidity and may be inadequate or insufficient in some clinical situations. Prior studies examining this issue have not provided definitive recommendations regarding implant selection, ideal locations in which to use specific implants, and necessary follow-up.

METHODS

First, the authors systematically reviewed the available literature on alloplastic implant use in rhinoplastic surgery by searching the MEDLINE database (from 1966 through September of 2005). Bibliographies from retrieved articles were searched for additional references. All data were independently extracted by two coauthors. Second, the authors performed a meta-analysis of the three most commonly used implant types.

RESULTS

Although a wide variety of alloplastic materials have been used historically and are still currently available, the most commonly used materials are silicone, expanded polytetrafluoroethylene (Gore-Tex), and porous high-density polyethylene (Medpor). In our meta-analysis, the removal rate for both Gore-Tex and Medpor implants was 3.1 percent, whereas the removal rate for silicone implants was significantly higher at 6.5 percent.

CONCLUSIONS

Alloplastic implants in rhinoplastic surgery have acceptable complication rates and can be used when autogenous materials are unavailable or insufficient. Outcomes with Medpor or Gore-Tex implants may be slightly better than those with silicone. Improved reporting of implant failures and follow-up times in future studies are needed to better define specific guidelines for the use of these materials.