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• W2030509322 abstract "JAMA Facial Plastic SurgeryVol. 15, No. 3 Free AccessSafety of Alloplastic Materials in RhinoplastyMyriam Loyo and Lisa E. IshiiMyriam LoyoDepartment of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.Search for more papers by this author and Lisa E. IshiiCorrespondence: Dr Ishii, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St, Baltimore, MD 21287 (E-mail Address: learnes2@jhmi.edu).Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.Search for more papers by this authorPublished Online:1 May 2013https://doi.org/10.1001/jamafacial.2013.787AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Over the past few decades, the use of grafts in rhinoplasty has increased in response to emphasis on the importance of structure and support. Where older techniques emphasized reductive rhinoplasty, long-term complications of nasal collapse, obstruction, and asymmetric healing and nasal deformities were noted. Appreciation of nasal structure and of long-term wound healing has led to modification of surgical techniques to achieve cosmetically pleasing results that maintain respiratory function and heal predictably. Grafting material is often necessary for the techniques that provide such long-lasting results.Generally speaking, the use of autologous grafting material is preferential to alloplastic materials. However, obtaining sufficient material, particularly in revision cases, can be challenging. Autologous rib cartilage provides abundant tissue but increases surgical time and carries donor site morbidity with the risk of pneumothorax. It also has the potential of warping. The appeal of alloplastic grafting material lies in the ease of obtaining an unlimited supply of material for grafting without added morbidity for the patient. Dorsal augmentation with silicone has long been advocated and remains a popular option in Asian countries.ref-qvp120003-1 However, historically, alloplastic grafting materials have been considered less desirable than autologous materials because of reports of infection, migration, and extrusion.In recent years, technological advances have led to the introduction of new biomaterials with better host integration than silicone. As a result, there has been an increasing number of publications describing the use of alloplastic material in rhinoplasty. We sought to review the current literature for the most commonly used alloplastic materials in nasal surgery to evaluate outcomes and complications associated with their use.LITERATURE REVIEWThe 3 most commonly used alloplastic materials in rhinoplasty are silicone, expanded polytetrafluoroethylene (GORE-TEX; W. L. Gore & Associates Inc), and porous high-density polyethylene (Medpor; Porex Surgical Inc). Silicone is a nonporous material that does not allow host tissue ingrowth and over time develops a thick capsule surrounding the implant. Most of the complications of silicone are thought to arise from the capsule and include infection and extrusion. GORE-TEX is composed of nodules of polytetrafluoroethylene interconnected by fibrils with pores ranging from 10 to 30 μm in diameter. Medpor consists of continuous interconnecting polyethylene pores ranging from 125 to 250 μm. The porosity of GORE-TEX and Medpor allows for host tissue ingrowth and neovascularization into the implant. Medpor has the additional advantage of being malleable. In a recent systematic review, Peled et alref-qvp120003-2 performed a meta-analysis of 20 studies examining these materials in rhinoplasty. In this review, the removal rate for both GORE-TEX and Medpor was 3.1%, which was significantly lower than the 6.5% removal rate of silicone implants. The extrusion rate was also significantly lower for GORE-TEX and Medpor than for silicone. No difference was found in infection rates between the different materials. Lower implant extrusion with porous materials may result from the tissue ingrowth seen in these materials. The studies included in the meta-analysis were retrospective case series with follow-up ranging from 1 month to 11 years. Studies with longer follow-up reported increased removal rates for silicone, suggesting failure rates increase over time. Notably, 6 of the studies did not report follow-up time. The report concluded that longer follow-up is needed to better define removal rates but found low complication rates with GORE-TEX and Medpor encouraging.The most common location for the use of alloplastic implants during rhinoplasty is the nasal dorsum. In 2011, Lee et alref-qvp120003-3 published a systematic review of surgical techniques used in dorsum management, including 27 studies examining alloplastic materials. In their review, synthetic materials had higher rates of complications than autologous material, including higher displacement and extrusion rates. Nevertheless, the synthetic materials still had relatively low complication rates. Alloplastic material extrusion rates ranged from 0% to 10.7%, while infection rates ranged from 0% to 3.7%. Most of the studies included in the review were retrospective case reports with follow-up ranging from 1 month to 12 years.The site of implant placement may have an impact on the complication rates. The use of synthetic materials in locations other than the dorsum is inconsistently reported in the literature. Winkler et alref-qvp120003-4 published a recent large retrospective case series that compared outcomes for 511 rhinoplasties with autologous grafting material vs 115 rhinoplasties in which Medpor and GORE-TEX were used. In their series, not only did the use of alloplastic material carry a higher risk of infection than that of autologous material (0% vs 12.6%), but also the infection rate varied by location. Medpor columella struts had the highest infection rate at 23.4%. The authors hypothesized that deficient skin and mucosa covering of the implant at the nasal tip may explain the increased rate of infection. Most infections led to implant extrusion (18 of 19 infected implants were extruded [overall rate, 11.5%]). The average follow-up was 12.1 months (range, 0-74 months).Most of the studies available for alloplastic material in rhinoplasty are retrospective case series with limited follow-up information. They are therefore subject to bias. In 2003, Wangref-qvp120003-5 reported on multicenter prospective outcomes for 31 GORE-TEX implants used in nasal surgery. Prospective studies have the advantage of minimizing recall bias. In the study, only 1 of the patients developed an infection and subsequently had the implant removed. There were no reports of implant migration or extrusion. The minimal follow-up was 3 months, but further follow-up information was not reported.The Table summarizes the findings for each reference. The limitations of the available literature on alloplastic materials in rhinoplasty include lack of prospective studies, small individual study power, and lack of detailed follow-up information. It is generally accepted that soft-tissue envelope contraction after rhinoplasty takes at least 1 year, thus making this a minimal desirable follow-up time in rhinoplasty studies. The specific time course of failure by extrusion in rhinoplasty has not been defined and may continue to increase over time. Infection and extrusion has been reported up to 3.5 years after implantation.ref-qvp120003-6 The literature has shown that different sites of implants carry different infection rates; however, the location of the implants is inconsistently reported in the available studies. In addition, the final complication rate may be underestimated in the literature given that patients developing complications may not present to their original surgeon for follow-up resulting in attrition bias. These limitations highlight the need for studies with a higher level of evidence on this topic. Finally, new alloplastic materials continue to be developed with promising initial results that will need to be confirmed with further studies.BEST PRACTICEAutologous cartilage remains the preferred grafting material in rhinoplasty. When additional material is required, a variety of alloplastic materials are available for use in rhinoplasty and include silicone, GORE-TEX, and Medpor. The risk of infection and extrusion with alloplastic material is higher than with autologous material and can occur many years after the initial rhinoplasty. Currently, existing data on complication rates from the use of these materials are limited. Although available data are encouraging for low rates of infection and extrusion, careful preoperative counseling is warranted. Future research is needed to define long-term outcomes for the use of these materials.In this Viewpoint, 2 level 2c studies (meta-analysis and systematic review of case series) and 2 level 4 studies (case series) were reviewed.Published Online: March 7, 2013. doi:10.1001/jamafacial.2013.787Conflict of Interest Disclosures: None reported.REFERENCESShirakabe Y, Shirakabe T, Kishimoto T. The classification of complications after augmentation rhinoplasty.. Aesthetic Plast Surg. 1985;9(3):185–192 3907311 Crossref, Medline, Google ScholarPeled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis.. Plast Reconstr Surg. 2008;121(3):85e–92e 18317090 Crossref, Medline, Google ScholarLee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications.. Plast Reconstr Surg. 2011;128(5):538e–550e 22030516 Crossref, Medline, Google ScholarWinkler AA, Soler ZM, Leong PL, Murphy A, Wang TD, Cook TA. Complications associated with alloplastic implants in rhinoplasty [published online August 27, 2012].. Arch Facial Plast Surg. 2012;14(6):437–441 Link, Google ScholarWang TD. Multicenter evaluation of subcutaneous augmentation material implants.. Arch Facial Plast Surg. 2003;5(2):153–154 12633202 Link, Google ScholarGodin MS, Waldman SR, Johnson CMJr. Nasal augmentation using GORE-TEX: a 10-year experience.. Arch Facial Plast Surg. 1999;1(2):118–121 10937089 Link, Google ScholarFiguresReferencesRelatedDetailsCited byComplications Associated with Use of Porous High-Density Polyethylene in Rhinoplasty Seth J. Davis, Kelly C. Landeen, Justin C. Sowder, Kyle S. Kimura, Karthik S. Shastri, Mark C. Clymer, and Scott J. Stephan1 September 2022 | Facial Plastic Surgery & Aesthetic Medicine, Vol. 24, No. 5Welcome to the New JAMA Facial Plastic Surgery! John S. Rhee and Wayne F. Larrabee18 July 2013 | JAMA Facial Plastic Surgery, Vol. 15, No. 4 Volume 15Issue 3May 2013 InformationCopyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Myriam Loyo and Lisa E. Ishii.Safety of Alloplastic Materials in Rhinoplasty.JAMA Facial Plastic Surgery.May 2013.162-163.http://doi.org/10.1001/jamafacial.2013.787Published in Volume: 15 Issue 3: May 1, 2013PDF download" @default.
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