Aesthetic Surgery of Nose

The Nose has not only commanded attention on its own accord for its size and shape but has governed Facial Aesthetics like no other part of the body. Not only does it define facial proportions but also influences the personality of the individual.

Aesthetic Augmentation of the Nose using autogenous and alloplastic material has come a long way. The variety of autogenous and alloplastic materials used over the ages is not only exhaustive but bewildering as well. This asserts the fact that perfection in this field is less than becoming.

The autogenous material includes the gold standard – bone and cartilage grafts. The range of alloplastic material attempted to extend from fingernails, injected paraffin, porcelain gold, and ducks breastbone to the more recent biocompatible polymers like Silastic, Proplast II Medpore, Mersiline, and Supramid.

We are presenting here a series of 65 cases that came to us between 1985 and 1999, for aesthetic correction of the Nose, primarily using Poly-Tetra-Fluoro-Ethylene (Proplast II) or expanded Poly-Tetra-Fluoro-Ethylene (ePTFE, GORE–TEX) essentially for an Augmentation of the Nasal Dorsum.

MATERIAL & METHODS:

Every surgeon faces obligatory situations in his practice where an alloplastic implant has to be considered. We have experience with silastic and Proplast but here we present our work with expanded Poly-Tetra-Fluoro-Ethylene (ePTFE, GORETEX, W.L Gore and Associates Inc, Flagstaff, Arizona)

This is a polymer of fluorine and carbon extruded under high pressure, through a dye to create a microporous material that has a weave of ePTFE fibrils interspersed with PTFE nodules. The internodal separation that approximates the pore size has an average internodal space of 22, which allows for limited tissue ingrowth and stabilization of the implant. ePTFE is available in a form and a reinforced form, which incorporates fluorinated ethylene propylene.

The material has multidirectional fibrils that internally reorient the nodes when uniaxial shearing forces are applied. This conforming property should not be interpreted as stretching as the surface area is still maintained. ePTFE was introduced clinically by Soyer et al in 1972, as a vascular prosthesis. Neel 1989 introduced it in Plastic Surgery following his histologic experiments on an animal model. To date, ePTFE has been used in mesh form for hernia repair and reconstruction, soft tissue deficiencies, cardiovascular patching, great vessel, and peripheral vascular reconstruction, etc.

The plastic surgeons’ hesitation in attempting new alloplastic material is well based on the promises and failures of previously well-publicized synthetic products, the use of ePTFE in various other biocompatible mode has established its reputation as a relatively inert, biocompatible and bioadaptable alloplastic implant.

But its use in ‘low threshold areas’ as in the nasal dorsi where the implant is superficial, under a shallow skin cover, and relatively proximate to a contaminated field (Nares) has not been undergoing considerable evaluation. Our report attempts to expand and add to this still lean body of information.

METHOD

Dorsal Nasal Augmentation essentially calls for a sculpture’s streak. The Plastic Surgeon should practice shaping the material in a lab and only when fully conversant and confident then only apply his skill in the Operating Room.

A couple of important points to consider whilst doing an Alloplastic Implant Surgery, moreover so in the case of low threshold recipient site like nasal dorsum are:

Maintain a “Super Sterile technique” that includes

1. The implant is maintained in original sterile packing until a subcutaneous recipient packet is created. Vide infra.
2. A change of gloves for the surgical team and the use of a fresh Operation trolley. A vigorous washing off of all of the powder
3. Use of virgin blades
4. Vacuum impregnation of antibiotic and maintenance of sculptured implant in the antibiotic solution until placement.
5. Insertion of an implant with no-touch technique
6. Keep handling of the implant to a minimum.

A thorough step-by-step appraisal of the procedure will now be discussed.

1. Pre-op consultation and documentation done.
2. External marking of the implant pocket is done.
3. Subcutaneous pocket dissected out through an inter-cartilaginous incision.
4. Sub-periosteal pocket dissected out with a periosteal dissector
5. Attention shifted to sculpturing of the implant once homeostasis was achieved and maintained.
6. The graft sculptures use 11 no and 15 no virgin blades and maintain the aforementioned super sterile technique.
7. Vacuum impregnation of the implant with an antibiotic.

1. Gentamycin 2 cc diluted in 30 ml of saline is taken in a 10 ml syringe
2. The implant is loaded into the syringe from behind.
3. The syringe is held upright and the plunger is pulled back, blocking the bevel with a gloved finger.
4. Small air bubbles will be seen emerging from the implant
5. The implant will sink down once it is fully impregnated

1. The implant is introduced into the subperiosteal pocket and the external pressure is maintained to co apt it to the bone surface. Incision closed and splinting of the implant done

Advice on Implant Sculpturing

1. A rough model made by crude strokes with 11 and 15 number virgin blades.
2. This is then feathered so that there are no rough edges.
3. The implant is shaped as per McCarthy’s description like the prow of a boat, beveling out gradually.
4. The undersurface of the implant is excavated to leave a depression that will help the implant to sit on the rhinion and not slide off onto either side.
5. To facilitate better tissue adherence vertical and horizontal hatching of the dorsal surface of the implant is done. This helps in preventing the migration of the implant.

Using a self-illuminated dorsal nasal retractor the cavity is cleaned of all tissue debris, bone fragments, fat fragments, and hematomas.

CASE DISCUSSION

1. A 28 yr old female professional graphic designer came to us with a severe saddle deformity of the nose and alar flaring
2. A 48 yr old male American mode; an ex boxer who had a punched up nose with bony deviation, fracture nasal septum and airway obstruction.
3. A 38 yr old female lawyer approached us with mild saddling of the nasal bridge.
4. A 20 yr old female with total hypoplasia of middle face, medial septum of nose. Tight skin cover and nasal lining came floor aesthetic correction of nasal bridge.
5. A 34 yr old doctor of preventive and social medicine who got a septoplasty done in childhood for a deviated nasal septum presented with severe supra tip deformity, flaring of ala and overhanging tip.
6. A 26 yr old Bengali gill presented with severe hypoplasia of the medial septum of the nose with poor definition of the nasal tip, a leftward deviation a short Columella and alar flaring.
7. A 32 yr old female with post small pox marks presented for aesthetic correction of the saddle nose with overhanging tip and alar flaring
8. A 28 yr case of mild binders syndrome Columella shortening
9. A 40 yr old gentleman with thick skin and bulbous nasal tip came to us for tip Plasty and dorsal nasal augmentation using an ePTFE implant.

CONCLUSION

The aforementioned results and the author’s tremendous experience with other autogenous and alloplastic material clearly reveal that ePTFE has presented a comfortable solution to subcutaneous augmentation needs on the nasal dorsum. Not only is it easily available, but it is also easy to sculpt and apply too. In patients where it is obligatory to use alloplastic material either for lack of donor site or massive augmentation e PTFE is making a mark.

References:

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*Honorary Plastic & Microsurgeon.
Bombay Hospital & Medical Research Centre, Bombay
*Suite No. 16, II floor. Laud Mansion, 21 M. Karve Road, Bombay – 400 004

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