There are numerous ethnic noses (Asian and African-American) that are characterized by having a low and wide nasal bridge. Such low nasal bridges are almost always associated with a tip of the nose that has poor definition and is wider and flatter. Rhinoplasty in this nose type requires the bridge and dorsal line to be built up higher. The choice in nasal augmentation is always between that of synthetic materials and one’s own bone or cartilage.
While I always prefer and use rib cartilage for significant nasal augmentation, some patients understandably do not want to have that done. This is particularly true in the patient who walks in for a cosmetic rhinoplasty without any prior nasal surgery. As a result, the use of synthetic implants, particularly composed of silicone, is the most commonly used nasal augmentation material around the world.
Synthetic nasal implants do have, however, a recognized history of problems such as infection, mobility, and even extrusion. This has led to the belief that all synthetic materials should be avoided in the nose. The extremely large experience in Asia with synthetic rhinoplasty, however, would indicate that this is not completely accurate.
Greater success in nasal dorsal augmentation with an implant is to place it, not just under the skin, but under the periosteum on the nasal bones. Elevating this periosteum can be difficult but is important particularly when the implant needs to be placed high on the nasal bones, which is usually needed in men. The significance of subperiosteal placement is that it will help prevent implant mobility and hide the edges of the implant better.
When it comes to nasal implants, what are our options today? The choices come to down material types (silicone vs Medpor primarily) and either a dorsal implant or an extended dorsocolumellar implant style. There are advocates for both material compositions and neither one is necessarily superior over the other. My preference is currently for a silicone-based material because of one factor…its ease of revision. Medpor gets a lot of tissue ingrowth which is biologically favorable. However, should it be necessary to revise it, it is a bear to get out. This translates into a fair amount of tissue disruption to remove it. Since the long-term potential for revisional rhinoplasty surgery is not rare with implants, I lean towards what would be easiest and least destructive to remove.
From a nasal style standpoint, I have concerns with an L-strut shaped implant. This implant comes down along the entire bridge of the nose, over or through the tip , and down to the base of the columella. (after turning 90 degrees at the tip) While it helps give the tip of the nose definition, it does so by putting point pressure in a fairly small area. This may make the nose tip too pointy and unnatural looking. (even a thin nose tip is round and not naturally pointy) With such pressure on the tip of the nose over time, it can become thin, get red, and ultimately develop extrusion. I have seen this more than once. The other problem with an L-strut is the potential for it becoming twisted and making the nose crooked. This can occur from simple scar contracture over time or from even slight trauma to the nose.
For these reasons, it makes more sense to me to keep an implant relegated to a dorsal style only. This places pressure over a much broader area of skin, lessening the risk of long-term tissue thinning problems. (provided it is not oversized) Once can usually find enough natural cartilage for tip and columellar grafting and support. It is the long dorsum where the implant provides its primary benefit of enough volume without a graft harvest Mobility and visibility problems can be improved with subperiosteal placement over the nasal bones as previously discussed. Modern dorsal nasal implants use a ‘saddle’ over the dorsal area for better fixation.
Some ethnic rhinoplasties need substantial dorsal augmentation as a foundation for its aesthetic success. When rib harvesting is not an option, a properly sized and placed nasal implant can have good long-term results.
Dr. Barry Eppley
Indianapolis, Indiana