Contemporary rhinoplasty employs three fundamental concepts, open exposure, cartilage preservation, and structural support. The latter, partially influenced by the second principle of cartilage saving, often involves the introduction of cartilage grafts in key support locations such as the columella, septum, middle vault, and the lower alar cartilages. This ideally creates a need for straight cartilage pieces and skill in harvesting cartilage in general from several different locations.
An alternative or adjunctive method for adding cartilage support is to use synthetically manufactured materials with or without cartilage components. A thin synthetic sheet or mesh could be cut into any straight shape of any length and provides as much support as any piece of cartilage. The use of this concept could simplify and shorten some rhinoplasty procedures and save the need for donor sites in others. It could also be a savior in cases where the patient is cartilage-depleted and rib grafts are the only option.
The key to synthetic materials in the nose is to use, when possible, a resorbable material and construct so that it doesn’t pose a long-term extrusion or infection risk. Resorbable materials, such as LactoSorb or PDS, have long histories of successful facial use and documented complete elimination of the material in one year or less after implantation. They can be manufactured in thicknesses 1mm or less which gives them some stiffness despite their thin quality. Like all synthetic materials, however, they should be buried under well-vascularized tissue to prevent extrusion before resorption can occur.
Resorbable thin sheets are useful in multiple rhinoplasty applications. An obvious use is for the temporary splinting of unstable or loose cartilage in septoplasty. Smaller pieces of cartilage can be assembled and sutured onto a sheet of material and then reimplanted. A second good use would be for columellar strut grafts, either with some cartilage and possibly even by itself. A third good application is for spreader grafts of the middle vault. Cutting long strips of the material makes for easy placement between the upper lateral cartilages and the septum. They can be used alone or with small pieces of cartilage grafts affixed to them.
One question to ask about this supplement to cartilage grafting (or cartilage graft replacement in some cases) is…what happens when the material weakens and eventually goes away. As a cartilage supplement, the cartilage should have healed enough so that the loss of the resorbable support does not matter. When used as a cartilage replacement, however, the outcome is not as clear. I suspect that it is influenced by how much material is used and how critical it was to the support area. As the material is absorbed, it will be replaced by some scar. Whether the residual scar can serve the same role as the resorbable construct is not yet known.
Dr. Barry Eppley
Indianapolis, Indiana