A Royal Pain in the Throat Tinnitus - ENT & Allergy Associates

“Wh a t ’s in a No s e ?”A h i s t o r i c a l r e v i e w a n d u p d a t e o nT h e u s e o f g r a f t s a n d i m p l a n t s i n rh i n o p l a s t yG u y Li n, M.D.Rhinoplasty is the 6th most commoncosmetic surgical procedure performedin the United States. Sincethe overall number of cosmetic proceduresperformed in this country continues to rise,physicians are faced with a growing numberof dissatisfied patients who present withcosmetic or functional complaints related toprevious rhinoplasty. Revision rhinoplastycan be performed to resolve a patient’s complaint,but only if there is an understandingof what material was used during the originalreconstructive procedure.Historically, the art of improving deformitiesof the nose by means of surgery was onlyunderstood in the context of reconstructionof a mutilated nose. The earliest recordedpublication that refers to rhinoplastyin an aesthetic context was in 1845, byDieffenbach. By the early twentieth century,American surgeons, John Roe and RobertWeir, as well as the German surgeon, JacquesJoseph, were simultaneously pioneering theart of performing cosmetic rhinoplasty.The surgeons developed their techniqueswithout knowledge of the work being doneon opposite continents. A current literaturesearch (at the time of this writing) lists 5343articles with the keyword “rhinoplasty”. Thiswealth of information has helped transformthe art of rhinoplasty into a science.The goal of rhinoplasty is achieving nasalbalance and establishing harmony withthe face while preserving a functionalnasal airway. Historically, rhinoplasty wasmostly reductive surgery. The aestheticideal has shifted to creating a natural lookwith long-term stability. This is achievedthrough a combination of reduction andaugmentation techniques, with an emphasison preservation of the existing frameworkof the nose. Graft and implant materials inrhinoplasty are used primarily to strengthenthe structural framework, to provide contouror camouflage defects, and to restore thenose to an aesthetic ideal.The ideal graft or implant material is biocompatibleand possesses physical propertiesand long-term stability devoid of complications.There are three broad categories ofgraft and implant materials that are currentlyavailable for rhinoplasty: autografts(derived from the patients own tissues);homografts (derived from tissues obtainedfrom a different donor of the same species);and alloplasts (implants that are either semisyntheticor entirely synthetic). Autogenousseptal or auricular cartilage is generally acceptedas the gold standard of nasal graftingmaterials, with the major disadvantage beingan insufficient amount due to prior trauma,surgery, or infection. Costal cartilageprovides the advantages of a large volumeof grafting material with excellent structuralsupport. The disadvantages are warping andpotential morbidity to the donor site. Thereis ample literature to support the use of cartilagegrafts with long-term success, withthe largest series including over 2000 graftsperformed over the course of 17 years withinfrequent complications.Homograft materials are not ideal substitutesfor autogenous grafting material because oftheir long-term unpredictability and thefear of disease transmission. Homologousirradiated costal cartilage has been shownto resorb on long-term follow up and hasthe potential to warp. Alloderm® is anotherhomograft that has been used as a volumefilling material as well as for onlayingover cartilage or other grafting material25