Nasal-Recon-slides-050420 - Alloplastic Implants and...

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Unformatted text preview: Alloplastic Implants and Homografts in Nasal Reconstruction Reconstruction Sarah Rodriguez, MD David Teller, MD UTMB Dept of Otolaryngology April 2005 Implants in Nasal Reconstruction Implants Historically, various materials Historically, used—some bizarre: used—some – Vaseline, paraffin, gold, Vaseline, silver, aluminum, porcelain, celluloid, ivory, cork, stones from the Black Sea, fingernails, toothbrush handle handle More recent materials include: – Metals (titanium), ceramics, Metals polymers (silicone, polyethylene, PTFE, polyesters, polyamides) polyesters, Goals Goals Create an aesthetically inconspicuous nose Create while preserving the functional aspect while Defects must be appreciated in three layers: Defects inner lining, structural foundation and outer covering covering Structural grafting is often required to: – Provide rigidity to the sidewall and resist lateral Provide collapse during inspiration collapse – Prevent cephalic retraction of the alar margin – Establish nasal contour and projection Use of Alloplastic/Homograft Material Material Preferred graft material to Preferred rebuild structure is autologous cartilage; however, however, – Cartilage may be in short Cartilage supply – Donor site morbidity may Donor preclude autologous cartilage harvest cartilage – Quality of available Quality cartilage may preclude use cartilage – Bone grafting has several Bone drawbacks as well drawbacks Options Options Alloplasts – Silicone – Porous High Density Polyethylene – Extended PTFE Homograft – Alloderm – Rib cartilage Solid Silicone Rubber [Silastic] Solid Solid, non-porous implant Solid, which is not incorporated into surrounding tissues surrounding Capsule-forming Elicits minimal inflammation ?Tendency to extrude/migrate Cannot be used in thin-skinned Cannot areas areas Used as L or I-shaped implant Used or the “bird” or Popular in Asian countries Silicone Silicone “A strong academic bias against the use of alloplastic strong materials in the nose persists in Western countries. Influential surgeons condemn silicone implants with the fervor of a Pentecostal preacher admonishing that their use in the nose constitutes a cardinal sin of rhinoplasty, obviously ignoring the fact that long-term results using this material in the Asian nose have been excellent. As a result, few Western surgeons who advocate augmentation of the Asian nose with alloplasts have reported their results, and those who dare to submit such reports often assume a deferential, quasi-apologetic posture.” McCurdy Facial Plastic Surgery, 2003 Facial Silicone Augmentation Results Silicone Ahn 2004: 100 silicone augmentation Ahn rhinoplasties with 2-5 yr follow up rhinoplasties – No extrusions; 5 patients revised for misalignment, 2 No for tip graft shifting, 1 for recurrent dorsal edema for Lam 2003: 1079 rhinoplasties with the “bird” – 3% infection rate; 3% displacement; no mobility or 3% extrusion encountered extrusion Several smaller series with low complication Several rates rates Complications of Silicone Implant Complications May induce skin May changes (atrophy, color changes, telangiectasia, swelling) swelling) Extrusion linked to Extrusion excessively large implants with overlying skin tension overlying Porous High-Density Polyethylene-PHDPE Polyethylene-PHDPE Medpor formed by sintering PHDPE particles Medpor together to form lattice with 100-250 micrometer pores pores Pore size allows for fibrovascular ingrowth of Pore tissue and does not form a capsule; less trouble with migration, more difficult to remove with Pore size large enough to allow ingress of Pore macrophages (>50 micrometers) macrophages PHDPE/Medpor PHDPE/Medpor Can be bent in hot, sterile Can saline and retain bend when cooled when Available as pre-formed Available dorsal graft, columellar strut, external valve batten graft batten Has been used in cleft-lip Has rhinoplasty, post-trauma reconstruction, revision rhinoplasty rhinoplasty Placement of PHDPE Implants Placement PHDPE Complications PHDPE Literature review documenting morbidity Literature associated with PHDPE implants (Yaremchuk, 2003) found low rate of infection and extrusion infection – Largest series of 187 patients receiving Largest multiple nasal implants reported 5 infections (3 early and 2 delayed) and no implant extrusions extrusions Expanded Polytetrafluoroethylene [Gore-Tex] [Gore-Tex] Relies on extremely Relies strong carbon-fluorine bonds bonds Nonstick and nonthrombogenic secondary thrombogenic to electronegative surface to Pores of 10 to 30 Pores micrometers micrometers Host tissue ingrowth Host occurs at periphery of implant only implant ePTFE/Gore-Tex ePTFE/Gore-Tex Has been used to augment Has nasal dorsum, lateral nasal wall, premaxilla, supra-tip area, columellar strut, radix, shield grafts, “total lower lateral cartilage reconstruction” lateral Literature review by Ham et al Literature in 2003 of 769 Gore-Tex rhinoplasties reports 18 infections and two cases of inflammation requiring removal inflammation Literature cites 2-3% infection Literature rate rate Alloderm Alloderm Acellular human dermis Acellular obtained from donated human skin skin Provides soft tissue Provides augmentation that is stable after an early period of resorption (6 months); must overcorrect overcorrect Can be used to camouflage Can contour irregularities created by alloplastic or autoimplants in nasal reconstruction in Irradiated Homograft Rib Cartilage Irradiated Appears to be stable Appears over time over Risk of warping Risk decreased if carved from core from Easy to carve and Easy stabilize with sutures stabilize Follow up IHCC Follow Clark (2002) reported 18 patients who Clark underwent removal of extruding alloplastic implant and replacement with IHCC. One pt required revision secondary to warping. required Burke (2004) reported on 118 patients receiving Burke IHCC with resorption compromising cosmesis in 11% 11% Dermirkan (2003) reported no resorption after Dermirkan use of IHCC in 65 patients Several other recent reports with low rates of resorption or other complications resorption Failed alloplastic materials Failed Proplast: no longer manufactured in United Proplast: States; PTFE implant which fractures into microfragments creating chronic inflammatory response response Supramid: polyamide mesh; undergoes Supramid: degradation with loss of bulk and is associated with severe inflammatory response with Mersilene: polyester fibrous mesh; acute and Mersilene: chronic inflammatory response which does not diminish with time diminish Tissue Engineered Human Chondrocytes Chondrocytes Methods of culturing Methods human chondrocytes is active area of research research Recently the Recently engineering of human nasal septal neocartilage described without use of biodegradable scaffold scaffold ...
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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