The use of Medpor ª alloplastic material in rhinoplasty: Experience and outcomes

Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) xx, 1e8

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The use of Medporª alloplastic materialin rhinoplasty: Experience and outcomes

Athanasios Skouras*, George Skouras, Dimitrios Karypidis,Fygalia-Anna Asimakopoulou

IASO General Hospital, 256 Mesogion Str., Athens, Greece

Received 6 January 2011; accepted 2 August 2011

KEYWORDSFunctional rhinoplasty;Medpor�;Alloplastic;Graft;Implant

* Corresponding author. Functional RE-mail address: skourasathan@yah

Please cite this article in press as: SJournal of Plastic, Reconstructive &

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.08.003

Summary Surgeons often avoid the use of alloplastic materials in functional rhinoplasty dueto potential complications.

The aim of the present study is to present the outcomes following the use of alloplasticmaterials in a large series of patients, to identify and document the possible complicationsand to offer insight regarding the safety and the indications of the method.Materials and method: Between February 2005 and August 2009, 58 patients underwent func-tional rhinoplasty using Medpor� alloplastic materials by a single surgeon (A.S). The majority ofthe alloplastic materials were used to reconstruct defects of the nasal dorsum as well as toaugment the columella and support the nasal tip.Results: Medpor� was used in the nasal dorsum in eight patients and in the columella in 50patients. There were 10 cases of primary and 48 cases of secondary rhinoplasty. Follow-up timeranged from 1 to 5 years (mean: 3 years). Complications concerned three cases of postopera-tive infection and material rejection. All cases were successfully re-operated.Conclusion: The use of Medpor� alloplastic material in functional rhinoplasty comprises a safemethod in selected patients due to the low complication rate, as shown in our series. It couldtherefore be considered as a useful alternative when reconstruction is problematic due to lowquality or lack of available autologous grafts.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

The use of grafts has been an established practice infunctional and aesthetic reconstruction of post-traumaticnasal defects and in secondary rhinoplasty. In addition, theapplication of grafting techniques has also been increasingin primary rhinoplasty.1

hinoplasty Department, 71 Voutsoo.gr (A. Skouras).

kouras A, et al., The use of MedpAesthetic Surgery (2011), doi:10.

tishAssociationofPlastic,Reconstruc

Standard use of autologous grafting includes cartilagi-nous grafts from costal and auricular donor sites and bonegrafts from the iliac crest.2 However, the use of autologousgrafts may be contraindicated when graft quality could beimpaired due to associated injuries or when donor-site

ina str., Holargos, Athens, Greece. Tel.: þ; 30 6944695985.

orª alloplastic material in rhinoplasty: Experience and outcomes,1016/j.bjps.2011.08.003

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

mailto:[email protected]

http://dx.doi.org/10.1016/j.bjps.2011.08.003



2 A. Skouras et al.

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morbidity and/or complications risk is high (e.g., followingprevious septoplasty).3

An alternative to autologous grafting is the use of allo-plastic materials such as silicone (Silastic sheeting, DowCorning, Midland, MI, USA), Proplast� (Vitek, Houston, TX,USA), Gore-Tex� (Elkton, MD, USA) and porous polyethylene(Medpor�, Porex, Newnan, GA, USA). However, the use ofalloplastic materials has been rather controversial due tothe high risk of infection, undesirable immunologicresponse and rejection that have been reported in severalstudies.4e7

The aim of this study is to present our experience con-cerning the use of Medpor�, (Medpor�, Porex, Newnan, GA,USA) in a large series of patients in a period of 5 years andto offer additional insight regarding the use of alloplasticmaterials in functional rhinoplasty. In addition, the low rateof complications in our findings could lead to the suggestionthat the disadvantages of alloplastic materials could havebeen exaggerated.8

Methods

During the period from February 2005 to August 2009, 58patients (44 female and 14 male) underwent functionalrhinoplasty by the senior author with the use of Medpor�

alloplastic material. The open method was performed in 47patients while 11 patients underwent the closed method.Forty-four of the 58 patients, who underwent rhinoplastywith the use of Medpor�, were male (75%) and 14 (24.2%)were female. Patients’ age ranged from 28 to 55 years(mean age 35 years). Primary rhinoplasty concerned 10cases (17.2%) and secondary rhinoplasty was performed in48 (82.8%) patients, who were primarily treated for nasalseptum deviation reconstruction and presented withundesirable aesthetic and/or functional results. Demo-graphics are shown in Table 1.

Surgical technique

In the closed method, bilateral marginal and transfixionincisions are performed and the alar cartilages are deliv-ered. In the open approach, a reverse ‘V’ incision is per-formed on the columella, which is subsequently aligned andunited with the bilateral marginal and transfixion incisionsand the columellaenasal dermocutaneous flap is elevated.

During dorsal defect reconstruction, the soft tissue ofthe nose is meticulously elevated from the underlyingosseocartilaginous nasal framework to create the appro-priate envelope, which will secure the alloplastic implant inits final position and prevent its dislocation.

Table 1 Patients’ demographic factors.

Demographic factor

MaleFemaleMean agePrimary rhinoplastySecondary rhinoplasty

Please cite this article in press as: Skouras A, et al., The use of MedpJournal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.

Two types of Medpor� alloplastic implants are used. Thefirst type includes the thin, 1.1 mm thick, columella struts,which are prepared in the appropriate dimensions intra-operatively, depending on the defect.9 The second typeincludes prefabricated nasal dorsum implants for dorsumdefect reconstruction.

In four patients, a columella strut (1.1 mm) was usedalong with two auricular cartilage grafts. The columellastrut was positioned in between the two cartilage grafts ina ‘sandwich’ fashion and sutured using 5/0 absorbable PDSsutures to increase the thickness and the resilience of thecartilage grafts.

The implants are usually kept in a sterile cup containing100 cc of natural saline, at 90e100 �C and 500 mg of van-comycin for 15 min prior to their use (Figure 1).10 They arethen surgically prepared to get their final shape and size,and appropriately positioned. More specifically, the colu-mella struts are positioned between the medial limbs ofthe alar cartilages and sutured using absorbable 5/0 PDSand 3/0 Vicryl sutures (Figures 2 and 3). The prefabricateddorsal implants are inserted in the pocket that has beenpreviously dissected in the nasal dorsum. Follow-upconsists of monthly office visits during the first 6 monthsand then of visits in 6 and 12 months’ intervals (Figures4e13).

Results

The open method was performed in 47 patients (19%), while11 patients (81%) underwent the closed method. Regardingtheir initial presentation, eight patients had significantdorsum defects and 50 patients had severe nasal tipdepression. A double dorsum-tip implant was used in onepatient.

Follow-up included postoperative office visits fora period ranging from 12 to 54 months (mean follow-up time33 months). Three patients experienced foreign bodyreaction and implant rejection. In all three cases, rejectionconcerned prefabricated dorsum implants. Two of thesepatients had previously undergone primary rhinoplasty.Rejection was noted on the 7th, 8th and 24th postoperativemonth in the aforementioned patients, respectively.

More specifically, the first patient had a history of cleftlip and multiple regional surgeries. In this patient, a doubledorsum-columella strut was primarily used for defectreconstruction. The dorsum graft was rejected andreplaced, while the columella strut was preserved. Thesecond patient presented with an extensive osseocartila-ginous and soft-tissue defect of the nose and had a longtobacco use history. The third patient had a severe dorsum

Number of patients

44 (75.8%)14 (24.2%)35 (28e55)10 (17.2%)48 (82.8%)


Figure 3 Placement of the Medpor columellar strut.Figure 1 Preparation of alloplastic implant before itsplacement.

Use of Medporª in rhinoplasty 3

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post-traumatic defect. In all three cases, the implants werecompletely removed and replaced by autologous osseousgrafts from the iliac crest. The aesthetic and functionaloutcome was satisfactory, according to what the patientsreported. These observations are summarised in Table 2.

Discussion

It could be suggested that rhinoplasty is one of the mostdemanding and frequently performed facial surgeryprocedures.11 The efficient reconstruction of nasal archi-tecture to restore nasal function resulting in an aestheti-cally appealing outcome has always been challenging forthe surgeon.12 Conversely, a poor aesthetic result or aninadequate functional improvement could be consideredunsatisfactory and may require secondary and/or revisionrhinoplasty.13

In the majority of the cases, secondary proceduresinclude augmentation rhinoplasty along with primarydefect reconstruction with the use of autologous grafts.14

Grafts may also be required in patients undergoing

Figure 2 Placement of the Medpor columellar strut.


primary functional rhinoplasty due to post-traumatic orpost-inflammatory deformities or acquired, age-relateddeformities.14

The ideal alloplastic material should have minimal or noantigenicity as well as similar texture, colour and biome-chanic properties to the tissue it substitutes.15 In addition,it should be easily prepared and fully integrated in thedonor site without increasing overall morbidity and the riskof inflammatory response.16

Septal autologous cartilage grafts have been the goldstandard in functional rhinoplasty over the past decades.17

Nevertheless, their use is limited when previous septalsurgery has been performed or in cases of recurrentinflammation and/or trauma. Similarly, septal grafts cannotbe used in regions where natural curvature and optimumnasal architecture need to be restored (e.g., alar carti-lages).18 Potential donor sites for autologous graftingusually include the costal or the auricular cartilage and theiliac crest.

The use of auricular cartilage grafts comprise a reliablemethod in cases presenting with external valve or alarcartilage defects, due to their natural curved

Figure 4 Preoperative profile picture of a patient with lossof tip support due to previous rhinoplasty.


Figure 5 2-year postoperative profile picture of the samepatient. A Medpor columellar strut has been placed for tipsupport.

Figure 7 Preoperative pictures of a patient with saddle nosedue to previous rhinoplasty.

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configuration.7 Conversely, their use yields poor resultswhen nasal tip support is required.7 In addition, persistentsurface irregularities even following morselisation limit theuse of autologous auricular cartilage grafts in dorsumdefect reconstruction.19

The preparation of costal cartilage grafts is ratherdifficult and the resulting graft configuration is oftencurved and prone to contraction, which leads to unpre-dictable and often undesirable outcomes.20 In addition,harvesting costal cartilage grafts has been associated withincreased donor site morbidity (e.g., pneumothorax).20

Figure 6 Preoperative pictures of a patient with saddle nosedue to previous rhinoplasty.


Iliac bone graft harvesting is usually followed byincreased donor site pain and has been associated withimpaired ambulation during the early postoperative period.

The aforementioned limitations regarding autologousgrafting led to the development of alloplastic materials andimplants addressing reconstructive requirements of thedorsum, tip and alar regions of the nose. Such alloplasticmaterials include silicone, Proplast�, Dacron�, Gore-Tex�

and Medpor�. Several authors agree that the three mostfrequently used materials are silicone, Gore-Tex� andMedpor�.6,21e32 Table 3 shows the findings in several studiesregarding the use of the aforementioned alloplasticmaterials.

Peled et al.1 reported that silicone had the highestrejection with subsequent removal rate, while all threetypes (silicone, Gore-Tex� and Medpor�) had similar risksfor infection.

Porous high-density polyethylene (Medpor�) has beeneffectively used in reconstructive craniofacial surgery forthe past 25 years. The size of the pores (125e250 mm)allows cell penetration and tissue ingrowth from the

Figure 8 1-year postoperative pictures of the same patient.A Medpor implant has been placed in the dorsum to correct thedefect.


Figure 9 1-year postoperative pictures of the same patient.A Medpor implant has been placed in the dorsum to correct thedefect.

Figure 11 Preoperative pictures of another patient withsaddle nose due to previous rhinoplasty.


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recipient bed as well as the effective neo-vascularisation inthe early postoperative stage.9,32 Early neo-vascularisationand soft-tissue ingrowth also leads to increased stabilityand lower risk for immune reaction, infection and implantrejection.

The wide range of shapes and sizes in which Medpor�

implants are available offers reliable reconstructive alter-natives in a similarly wide range of nasal defects. Anotherimportant aspect of the Medpor� implant is its white col-ouration,whichmakes it invisible under the skin. In addition,implant resorption is minimal and its biomechanical prop-erties provide adequate resilience and durability. In warmsaline, the implants become pliable and can be preparedusing scissors in their final desirable size and shape. Finalshape is maintained after subsequent cooling.32

Rejection rate in our series reaches 5.1%, which issubstantially low compared with previous reports con-cerning alloplastic materials.6,21e32 According to severalstudies, the risk of immune response and implant rejectionis higher in patients who have undergone multiple regional

Figure 10 Preoperative pictures of another patient withsaddle nose due to previous rhinoplasty.


surgeries, as they are more prone to developing localischaemia and cellulitis.20 Consequently, patients withpost-traumatic and post-burn defects who have undergonemultistage nasal reconstruction as well as heavy smokers orpatients with impaired general health condition are not theideal candidates for the use of alloplastic materials. In allthree cases of implant rejection in our series, there wereone or more of the aforementioned parameters present,which are associated with poor prognosis in reconstructionusing alloplastic materials. In addition, all three of therejected implants were positioned in the nasal dorsumdirectly under the skin. Conversely, no complications wereobserved in cases where the columella struts or the sand-wich configuration dorsum implants were used. Presum-ably, in the latter, the autologous grafts on each side of theimplant protect it from an early host response and enableits uninterrupted and uniform integration. The prospectiveof using autologous tissue, such as temporal fascia grafts,to prevent early implant rejection especially in patientswith poor regional blood supply comprise a topic of ongoingcurrent research in our Clinic.

Figure 12 2-year postoperative pictures of the samepatient. A Medpor implant has been placed in the dorsum tocorrect the defect.


Figure 13 2-year postoperative pictures of the samepatient. A Medpor implant has been placed in the dorsum tocorrect the defect.

Table 2 Complications in patients undergoing rhinoplasty using

Implant rejection R

Patient A 7th month SePatient B 8th month SePatient C 24th month PMean follow-up 33 months

Table 3 Characteristics and complications of several studies.

Study Implantmaterial

No. ofpatients

Infection(%)

Lipshutz (1966)21 Silicone 12 0Davis and Jones (1971)22 Silicone 62 1 (1.6)Hiraga (1980)15 Silicone 954 NRDeva et al. (1998)23 Silicone 422 0Zeng et al. (2002)24 Silicone 98 0Lam and Kim (2003)25 Silicone 1079 28 (2.6)Shirakabe et al. (2003)33 Silicone 224 NRTham et al. (2005)26 Silicone 355 19 (5.3)Waldman (1991)27 Gore-Tex 17 0Owsley and Taylor (1994)6 Gore-Tex 106 0Conrad and Gillman (1998)28 Gore-Tex 189 5 (2.6)Mendelsohn and Dunlop (1998)29 Gore-Tex 30 3 (10)Godin et al (1999)30 Gore-Tex 309 10 (3.2)Lohuis et al (2001)31 Gore-Tex 66 0Ham and Mille (2003)19 Gore-Tex 55 0Wellisz (1993)9 Medpor 27 2 (7.4)

Turegun et al. (1998)32 Medpor 36 0

Romo et al (1998)7 Medpor 187 5 (2.6)

Niechajev (1999)8 Medpor 23 1 (4.3)

Yaremchuk(2003)17 Medpor 13 0

NR, Not reported.a Only 63% of patients with reported follow-up.

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The primary reasons for the relatively low complicationrate in our series have therefore been:

(1) Multiple previous surgical procedures increase theincidence of graft rejection due to the altered localtissue quality and architecture. Using alloplasticmaterial in secondary rhinoplasty has therefore beena relative contraindication due to the high risk ofrejection. Consequently, meticulous patient selectionand excluding cases with a history of multiple previoussurgical procedures in the area may lead to the overalldecrease of complication rate including rejection.

(2) Negative prognostic factors in the medical history ofthe patients, such as tobacco use and wound healingimpairing medications (e.g., corticosteroids andchemotherapeutic agents), can also be screened outand further reduce the incidence of graft rejection.

(3) Local tissue blood supply and adequate vascularisationcomprise a major prerequisite for successful graftintegration and take. In cases where local blood supply

alloplastic implants.

hinoplasty History

condary Cleft lip, double columella strutcondary Osseocartilaginous defectrimary Post-traumatic nasal dorsum defect

Extrusion(%)

Implantrevision(%)

Implantremoval(%)

Follow-up(mean)

3(25) 0 3(25) NR10 (16.1) 10 (16.1) 11 (17.7) NR32 (3.4) NR NR NR2 (0.5) 0 41 (9.7) 6 yr (mean)a

2(2) 0 2 3 mo-5 yr (NR)0 0 52 (4,8) NR0 12(5,4) 0 NR10 (2.8) 14 (3.9) 14 (3.9) 3 mo-3 yr (5.3 mo)0 0 1 (5.9) 1-3 yr (NR)0 4 (3.8) 2 (1.9) 4 wk-5 yr (NR)0 9 (4.7) 7 (3.7) 3mo-6yr (17.5 mo)0 2 3 (10) Minimum 18 mo (NR)0 0 12 (3.9) 5 mo-10 yr (40 mo)0 0 1 (1.5) 3 mo-6yr (17.9 months)0 0 0 1 mo-5 yr (NR)2 (7.4) 2 (7.4) 2 (7.4) NR

1 (2.8) 1 (2.8) 0 14 mo (mean)

0 0 6 (3.2) 6 mo-3.5 yr (26 months)

1 (4.3) 1 (4.3) 1 (4.3) 1-3yr (2yr)

0 1 (7.7) 0 0-11 yr (27 mo)



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has been impaired or compromised (the aforemen-tioned factors of tobacco use, concurrent medications,multiple previous nasal surgeries, excessive previousregional trauma, impaired general health condition andassociated illness-systemic diseases), the use of allo-plastic material is relatively contraindicated

(4) Accurate and efficient pocket and recipient-sitedissection in terms of securing the alloplastic materialfrom unpredictable displacement and providingadequate and atraumatic soft-tissue coverage are ofparamount importance towards keeping rejection rateslow. Adequate recipient-site closure is also mandatoryto avoid infection and subsequent rejection of thealloplastic material. Experience and surgical skills aretherefore required to perform procedures including theuse of alloplastic material.

(4) Airtight recipient-site closure is also mandatory toavoid infection and subsequent rejection of the allo-plastic material. More specifically, in the open proce-dure, the marginal and columella incisions and, in theclosed method, the intercartilaginous and transfixionincisions have to be meticulously sutured. It is worthmentioning that, in our experience, the importance ofefficient incision closure is comparable with that ofsterilisation process.

To our knowledge and according to the available liter-ature,6,21e32 our clinical series of 58 patients is among thelargest ones while the follow-up period of 54 months isclearly the longest one.

Conclusively, according to our findings, the use of poroushigh-density polyethylene (Medpor�) implants in nasalreconstruction comprises a reliable and relatively safemethod following meticulous patient selection and whenperformed by experienced surgeons.

This article concerned a case series, a descriptive-observational study of evidence level III. Descriptive statis-tics have been used to demonstrate the efficient use ofalloplastic materials in rhinoplasty. The lack of controlgroups and the non-experimental nature of the researchdesign of this study prevented further statistical inferences,comparisons and analysis, other than what has beendemonstrated in the included population. Overall, it couldbe suggested that the use of Medporª alloplastic material isan effective and often valuable alternative when autologousgrafting is not possible. The combined use of alloplasticmaterial and autologous grafts in various configurationsprovide a ‘barrier’ of protection against early host immuneresponse and potential implant rejection.

Disclosure

None of the authors has legal, commercial, financial or anyother association and/or interest concerning the use of thealloplastic materials presented in this study.

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The use of Medpor ª alloplastic material in rhinoplasty: Experience and outcomes