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With an ever increasing ethnic population in the United States, dorsal augmentation has become a fairly common accompaniment to rhinoplasty. But procurement of adequate graft material of suitable nature and amount persists as a challenge to plastic surgeons. This dilemma has become even more pressing in recent years as a variety of other exceptional graft applications for the patient's limited cartilage bank have become not just an option but also mandatory for our higher expectations. The debate of the past century over alloplast in the dorsum persists in the present. “When and if ever” is the commonly asked question. Surely, no alloplast can match the ideal graft, but no graft is ideal either as it always comes in limited supply. There is now more than 15 years of experience with expanded polytetrafluoroethylene in the nose. It appears that with proper patient selection and technique, expanded polytetrafluoroethylene can be used in the nasal dorsum with relatively low complication rates and high patient satisfaction.
Predictable, aesthetic, safe, long-term dorsal augmentation remains an elusive goal in rhinoplasty. There is general consensus that autologous material is best. And there is widespread agreement that septal cartilage is most ideal with its minimal donor morbidity and excellent carving characteristics. Further, it has long-term reliability; stiffness, so it can add strength as well as volume; and properties that can be reliably altered with scoring, crushing, and bruising. But dorsal augmentation demands a considerable portion of a patient's available septum. And as rhinoplasty evolved from a destructive to a structurally based procedure, there developed a myriad of other applications for cartilage with the septum almost always the most optimal source. The rhinoplasty surgeon then was confronted with the harsh reality that this building block is in woefully limited supply. It is a dependence problem like the ongoing oil crisis but worse because we cannot buy a gram more no matter what we are willing to pay. With modern rhinoplasty, we have developed an “addiction” to septal cartilage. Our newer techniques have created the sculpture material shortage, but our standards are now too high to go back to old destructive, less predictable ways.
The shortage of septal cartilage every year actually becomes worse in both real and absolute terms. More and more patients have had prior septoplasty or rhinoplasty. Increasingly greater numbers of ethnic patients are seeking a more Western look, and these individuals often have less septal cartilage and are more apt to be desirous of dorsal augmentation. Concurrently, there are equal or higher priority graft applications for each patient's limited septal cartilage. In a great majority of my rhinoplasties, I am now using many of the following grafts: spreader, alar contour, lateral crural strut, tip, septal extension, and batten. This list does not even mention dorsal augmentation, which tends to consume more volume of cartilage than any other graft application, robbing from or negating other graft uses. And further, it not uncommonly demands a volume that even all the septal graft material cannot supply. With limited septal cartilage, the surgeon backs into the dilemma “do I compromise here or there?”
Conchal cartilage is readily available but with much more fibrous, brittle, and elastic physical properties. Its natural curled shape is ill-suited for the dorsum and if forced out of its resting orientation by sutures or scoring, it not uncommonly wins the battle years later with lump or bump irregularity showing up under thin dorsal skin.
Rib grafts have become extremely useful in rhinoplasty with unparalleled available volume and an excellent stiffness for strength in certain applications. There would be considerably more dorsal graft applications if it were not for three shortcomings. First, the chest scar and related pain are hard for many patients to accept. Harvest has a small inherent risk of lung collapse, and for larger rib pieces, such as fifth or sixth rib, this may steer the case away from the office operating room to the hospital or surgery center with higher costs for the patient. The most serious shortcoming though is warpage, a problem no technique can eliminate completely. Permanent buried K-wires are of considerable help with this.1 Extended intraoperative observation time can be useful to indicate direction and amount of warp prior to final carving.2 Adams et al3 found this period of intraoperative observation useful, but they noted continued warping over time for at least 4 weeks. This can explain the delayed postoperative nasal deviation from rib grafts. Sheen4 has tried many ways to alter rib through morselizing and slicing and still summed up his experience in the quest for controllable and smooth results as, “We are not there, but we are getting closer.”
Both the rib and the conchal cartilage can be employed for dorsal augmentation through dicing. This was initially reintroduced to modern rhinoplasty by Erol.5 As modified by Daniel and Calvert,6 it appears that resorption is minimized. I have found this useful in selected patients.
Thus, where do we turn with this sculpturing material shortage for dorsal augmentation when adequate septal cartilage is not available? Rib is an excellent material but it has its significant morbidity and/or revision risks. In this light, and considering there is now more than 15 years of experience with expanded polytetrafluoroethylene (e-PTFE) in the nose, this material appears quite appropriate for some cases needing dorsal augmentation. With experience and proper patient selection and technique, the reoperation rate can be quite low. e-PTFE can be removed easily in the case of infection based on my experience with its use in the lips and other areas of the face. In my 14 years of private practice, I have had one infection with rib grafts, but no infections with 27 dorsal nasal applications of e-PTFE. I have also found rib more likely to need revision for later irregularities or crookedness than this material.
e-PTFE is an expanded, strongly hydrophobic, fibrillated, carbon fluorine polymer.7 A fibrous mesh network interconnects nodules of polytetrafluoroethylene making a three-dimensionally amorphous structure. The porous microgeometry plays a role in tissue ingrowth.8 Pore size ranges from 0.5 to 30 μm.7
This material has been available in a variety of shapes and sizes both reinforced (more stiff) and nonreinforced (more compressible). It has been marketed to plastic surgeons as GORE Subcutaneous Augmentation Material (S.A.M.) by the company W.L. Gore and Associates, Inc (Flagstaff, Arizona). Since early 2007, though, these specific products have no longer been available. Only the softer e-PTFE sheets (GORE-TEX® Soft Tissue Patch) produced for cardiovascular and general surgical markets are available and are thus used in an “off-label” fashion. These sheets can be obtained in 1-mm and 2-mm thicknesses. One can also use e-PTFE that has been designed for vascular use, which comes in 0.9-mm thickness, which can be layered, if needed, as well.9 Adamson describes this application and mentions making 18 needle holes for better tissue fixation.
There are several principles in avoiding complications with e-PTFE in the nose. The most important is eliminating isolated pressure points on the lining or skin. This rules out applications in the tip or the columella. Every extrusion or impending extrusion that I have seen has been the much more stiff silicone or polyethylene materials causing pressure on a site of the lining or skin around the tip. Eliminated the stiff material and avoiding these risky locations and these problems can be nearly eliminated. I have not seen an extrusion or an impending extrusion with e-PTFE in the nose. Most dorsal grafts extend full length to the supratip area, and there the material is adjacent to the lining and at the most risk. Thus, carve narrower in the supratip and consider fixating it in the midline there.
The next most important principle is based on studies now published with up to 10 years of experience with e-PTFE applications to the nose.10,11,12 e-PTFE is least likely to lead to problems long-term in the setting of primary rhinoplasty and probably should be avoided completely in the setting of septal perforation. Finally, I employ e-PTFE in the nose with a higher level of sterility than that with autologous grafts. Carving is done on a separate table with fresh gloves and all fresh instruments. Silicone sizers similar to what Gunter uses for shaping rib grafts are useful (Fig. 1).1 It is inserted only through an open approach and only if there is no communication with the intranasal cavity. I prefer to avoid osteotomies in these cases, but that is usually not difficult. Dorsal augmentation can give the illusion of narrowing, and so osteotomies often are not necessary.13 Further, I not only soak the material in bacitracin, but I also, with negative pressure inside a syringe, infiltrate bacitracin into some of the materials' interstices (Fig. 2). I cannot say there is any proof that this is necessary, but it also adds a little stiffness to the material, which I find helpful. I also spray bacitracin under high pressure with a 3-cc syringe and a 30-gauge needle to the domes and columella late in the case as with every rhinoplasty, making infection in those areas nearly nonexistent. This limits the risk to the adjacent implant. Diabetics and other immunocompromised patients are not good candidates for e-PTFE. The most likely cause of revision is not infection or extrusion but asymmetry or irregularity. Do not assume any dorsal convexity at the end of the case is due to swelling. Sculpt the material to the right contour in surgery. Mark the very midline at the radix area preoperatively and make the pocket in the radix area a little narrow initially and exactly midline.
Most of my experience, since beginning use of this material in 1995, has been with the reinforced material. As this is no longer available, I stack usually 2-mm sheets, suturing them together, still beveling laterally. Carving on a hard surface requires replacing the no. 10 blade several times . Two representative cases are shown in Figs. Figs.33 and and44.
Conrad and Gilman10 had a 2.7% complication rate in their 6-year experience with Gore-Tex. Godin et al11 reported a 2.2% incidence of infection in their 6-year study of e-PTFE in rhinoplasty. This same group published their 10-year experience in 1995, reporting a 3.2% rate of graft infection.12 They found infection requiring removal among primary rhinoplasties at 10 years was 1.2%. In revision rhinoplasty, it was 5.4%. In the setting of septal perforation, problems were so frequent that they deemed it a contraindication for placement of Gore-Tex.
Published yet another 10 years after these reports, one of the above authors, Calvin Johnson, in his A Case Approach to Open Structure Rhinoplasty14 illustrates several cases employing e-PTFE in both primary and secondary rhinoplasty. As to the setting of prior surgery or trauma, he comments:“Gore-Tex may be safely placed under scarred skin if the S-STE [skin–soft tissue envelope] is not too thin.”14 Multiple case studies of applications of Gore-Tex both reinforced and nonreinforced are shared with intraoperative photos and discussion.
The above complication rates do not reflect problems years beyond the study period. Adamson9 has more than 15 years of experience with e-PTFE and continues to use it but less often and selectively. He had a diabetic patient extrude the material 9 years postoperatively. Papel15 uses e-PTFE selectively. He has seen infection 1 year postoperatively from renal sepsis.
My own experience with this material is 27 patients over 12 years with no infections or extrusions. e-PTFE clearly has a place in my practice for the proper indications and well-informed patients. Alternatives are always offered with a thorough discussion of all pros and cons. I make sure my patients understand the difference between a graft and alloplast, that an alloplast can cause problems even many years later, and that there are some surgeons that do not use alloplast in the nose.
e-PTFE does not replace all dorsal rib in my practice. Considerably scarred, multiple revision noses and noses that require the stiffness of rib for tip manipulation and rotation control may be better served with rib.
As to choice of thickness of dorsal e-PTFE, computer video-imaging using a photo with patient holding a ruler for calibration is very useful. I use the Mirror software (Canfield Imaging Systems, Fairfield, NJ) The 4.5-mm-thickness, reinforced material has been extremely useful for many Oriental patients. The nonreinforced sheets available now are softer. I am sure there is some degree of compression, and I may consider this in the future as I use more and more of this material. I have asked W. L. Gore and Associates, Inc., about the amount of compression that may be occurring, but they had no information on that. It surely is not a large factor.
e-PTFE is extremely useful for radix augmentation as it carves so well and can be made to taper so finely at its edges. More commonly, it is applied to the entire length of the dorsum. It should be mentioned that another option with stacking of layers of e-PTFE is rolling the material (R. Konior, personal communication), but I have no experience with this.
Other than significant dorsal augmentation, e-PTFE as a thin sheet can be applied to ensure smoothness of the dorsum. Perkins (S. Perkins, personal communication) describes this use as “blanket graft.” He uses it over the dorsum and sometimes over dorsal grafts such as concha. He does not see infection as a problem but does estimate a 5% revision rate for small surface irregularities. He finds there are sometimes erythematous changes to the overlying skin at a rate of 5 to 10%. I have seen this as well on occasion, but it appears well tolerated by patients.
In those rhinoplasties where dorsal augmentation is indicated, we should still consider autologous materials first. At times, though, autologous material is in limited supply or has a donor-site morbidity unacceptable to the patient. Autologous grafting to the dorsum has its own significant complication rate. e-PTFE has a similar if not lower total complication and revision rate with proper technique and patient selection and no donor morbidity. One must balance these alloplast attributes with the disconcerting but very small possibility of a problem many years later such as with development of immunocompromised state or trauma.