Background: Rhinoplasty surgeries fundamentally fall into the three main types, reductive, rehaping and augmentative. A reductive rhinoplasty is where bone and cartilage tissues are removed and none are added and the overall goal is to make the entire nose smaller. A reshaping rhinoplasty is where most of the manipulations are done by suturing and small amounts of tissue removal and grafting are done but the overall size of the nose remains the same. An augmentative rhinoplasty is where the entire nose is built up with the goal of an overall larger or more prominent nasal shape seen.
The augmentation rhinoplasty is often done in certain ethnic noses such as Asian and African-American patients. When building up the nose along the bridge, also called the nasal dorsum, the debate is almost always between using a rib graft harvested from the patient or using an implant out of a box. This is an historic debate and one in which surgeons often are staunch advocates of either approach. The reality is that the use of rib grafts and implants in the nose both have their advantages and disadvantages and the patient should be educated on both dorsal augmentation options.
When using nasal implants, there are two fundamental types of dorsal implant styles. (Implantech Nasal Implants) The Style 1 dorsal nasal implant (or Rizzo dorsal nasal implants) provides a full length dorsal augmentation with height increases up to 5mm. It is a tapering implant that is about 1 cm at the radix area and tapers down to 5mm near its full length near the tip. (4.5 cm long) The Style 2 nasal implant (or Flowers dorsal nasal implant) is a flatter and broader implant design designed more for a mid-dorsal augmentation effects with height increases up to 4.5mm. It is more uniformly wide at 1.2 cms in width.
Case Study: This 22 year-old Asian female was undergoing a variety of facial reshaping procedures including that of the nose. She wanted her nose built up with more dorsal height and tip projection. The options of using a rib graft or a synthetic nasal implant for her dorsal augmentation were thoroughly discussed.
Under general anesthesia and through an open rhinoplasty, a style 1 (Rizzo) dorsal nasal implant (medium size) was placed through a tight subperichondrial/subperiosteal pocket up to the radix of the nose. The lower end of the implant was located behind the tip of the nose. The tip cartilages were augmented using a septal cartilage columellar strut and tip reshaping sutures.
While nasal implants often have a bad reputation due to potential complications in the thin skin of the nose, it is important to separate dorsal nasal augmentation from dorso-columellar nasal augmentation. The incidence of complications changes dramatically from placing an implant on the bridge of the nose from one that extends further downward over/under the tip of the nose. Pushing on the tip of the nose with an implant, unless it is well protected and insulated from the skin over the tip of the nose by a cartilage graft, is a setup for long-term nasal problems. (thinning of the skin, implant exposure) While dorsal nasal implants are not free of complications (primarily shifting or midline asymmetry), they can be used very successfully with a low rate of complications.
Highlights:
- A dorsal nasal implant offers a synthetic alternative to the use of rib grafts in rhinoplasty.
- Different styles of dorsal nasal implants exist which are fundamentally different based in their width and height.
- Dorsal nasal implants are often part of an overall augmentation rhinoplasty done through an open approach.
Dr. Barry Eppley
Indianapolis, Indiana