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Nose Implants for Asian Patients

Most Asians require some type of augmentation rhinoplasty and there are many choices of implants, each with advantages and disadvantages. Dr. Rizk will discuss why he does not use silicone, which is popularized in Asian countries and why he chooses to use either cartilage implants or medpor. Additionally, proper patient selection, accurate shaping of implants, good intraoperative technique, good aesthetic sense of the surgeon and complications will be discussed.

For augmentation rhinoplasty in Asian noses, the goal is to choose the proper implant which provides longevity and a low resorption rate, using a stable implant which integrates, is easily shaped and sculpted and has a low infection rate. It is very important with implants to choose patients selectively and to use accurate intraoperative techniques with deeper placements of the implants to deter extrusion rates. Dr. Rizk has an accurate 3D method of intraoperatively placing implants. Many implants that Dr. Rizk sees in revision rhinoplasty were placed too superficially with not enough cushion between the skin and the implant.

Proper Patient Selection for Implants
This is a critical aspect of any operation but especially when implants are used, whether foreign (alloplastic) or from the patient (septal or ear cartilage). Dr. Rizk’s goal is to achieve a natural look via subtle augmentation of the nasal dorsum and projection of the tip. An Asian face cannot accept a Caucasian nose as it will lose harmony with other facial features. The most the surgeon should strive for is a Eur-asian nose. The patient cannot have any immune compromising disease or diabetes which would increase the likelihood of an infection. Patients need to be healthy and need not have recurrent sinus infections which may contaminate the foreign (alloplastic) implant. In Dr. Rizk’s opinion, the single most important factor for the success of the operation is the depth of placement of the implant away from the skin and the thickness of the skin. Deeper implant placement and thicker skin minimize the incidence of implant extrusion.

Solid Silicone implants for nasal augmentation are considered the implant of choice in Asian countries, but Dr. Rizk sees many extrusions, movements, infections and complications from silicone. Pictures will illustrate these problems. Additionally, accurate shaping of silicone is not possible because it has a very smooth, slippery surface which does not integrate into the nose. The silicone has been popular because it is affordable and available. In the United States, silicone implants currently are being used for breast augmentation and chin implants and cheek implants, but is not popular as nasal implants. They were introduced in early 1950's and are a rubber-like substance which does not resorb. When these implants are placed under the skin, fibrous encapsulation (not integration) occurs within 10 days. There is also a moderate inflammatory reaction that begins to resolve in 4 weeks. Studies in humans have shown no evidence of carcinogenesis with silicone rubber implants.

Accurate Shaping of Implants
During Dr. Rizk’s many years of experience, Dr. Rizk has removed many nasal implants from patients that have been placed by other surgeons. What is very clear from these implants is the lack of artistry or patience in shaping them. Shaping of the implant is done by Dr. Rizk with a new smoothing machine he adapted for shaping implants. Dr. Rizk is the first surgeon to shape implants using rotating micro-sanding powered machine he patented for this use instead of traditional methods with the knife. Dr. Rizk's techniques results in a very smooth surface and can be much more precise in the shape of the implant. Avoidance of sharp edges in implants is important because it gives a natural and smooth result and allows for better tissue integration.

Dr. Rizk customizes each implant and sculpts his own implants, rather than use a preformed factory implant, because there is so much variation among Asian noses. The shaping must be accurate, and the implant basically is custom-made for each individual patient. Particular attention is directed to the infraglabellar area, the bridge, the nasofrontal angle, the supratip area, the tip, and the infratip area. The nasofrontal angle should be preserved when determining the new height of the bridge of the nose. An important factor in this regard is the degree of prominence of the forehead and the chin area. The implant should be narrow and tapered as it approaches the infraglabellar area. It should be slightly concave as it approaches the tip in a female patient and straight in a male patient. The tip of the implant is rounded with no sharp edges and should be slightly higher than the bridge. This tip is located just proximal to the infratip area. Occasionally, if the tip of the nose is high enough, a partial implant is used which ends at the supratip area. The implant should not be too large or exert pressure on the skin which can thin the skin over time and cause extrusion.

Good Intraoperative Technique
The dissection must be deep inside the nose over the dorsum under the muscle layer. This is visualized by Dr. Rizk's endoscopic 3D high definition camera/telescope system. Dr. Rizk was the first to use this system for increased precision of implant pockets in rhinoplasty and for a more accurate operation (see videos on homepage from the Doctor's show on 3D high definition rhinoplasty). A superficial dissection will necessarily result in a thinner overlying nasal skin and, thus, predispose the area to early pressure necrosis. The pocket for the implant should not be too small or too large. An ideal pocket for the implant should be 1.2 times the width of the implant to provide allowance for contraction of the skin and integration with scar tissue. The dissected pocket should be in the midline, because if it is left or right of the midline, the implant will be off-center. Hematoma formation may also push the implant to either side, if not corrected, it will heal and adhere in this position. The implant may also move with early trauma to the nose so patients have to be very careful not to traumatize nose in the first month after the rhinoplasty. Dr. Rizk also sutures implant to avoid movements superiorly or inferiorly. Dr. Rizk also usually resects the depressor septi muscle located just underneath the columella which helps prevent implant movement as well as future drooping of the nasal tip.

Good Aesthetic Sense of the Surgeon
Although the aesthetic sense of each individual surgeon is variable, the most important consideration is that the surgeon's taste coincides with that of the patient. One should consider the sociocultural background as well as expectations of the patient and agree on the desired end result. An Asian or African patient would not desire a Caucasian-type nose, nor would it be in harmony with their features. Also, one should consider the shape of the face, the forehead, and chin prominence, the intercanthal width, and the height of the patient. The key concept is harmony of facial features to produce a natural look. I have always maintained that it is better to undercorrect, avoiding the risks inherent in the use of a larger implant. The majority of patients prefer a natural look; a dominant nose may change the total appearance of the face.

Complications: Prevention and Management
Bleeding/hematoma formation: The amount of swelling is directly proportional to the amount of bleeding. Bleeding is influenced by patient factors such as intake of aspirin and certain other medications, surgery during the menstrual period as well as surgical technique and technology used. Dr. Rizk uses a technique he designed using mini-3D high definition camera systems to achieve a rapid recovery by avoiding muscle and blood vessels which cause swelling and bruising and to increase surgical precision and decrease scarring. If a hematoma occurs, aspiration of the liquefying clot is usually successful.

Infection: More common with alloplastic implants which do not integrate like silicone than cartilage or medpor. Once infection occurs, general principles of plastic surgery state that the foreign body must be removed and appropriate antibiotics administered. Occasionally, one is tempted to procrastinate and delay the removal of the foreign body implant while the patient is given large doses of antibiotics. Rarely, this may be successful, but eventual removal of the implant is the rule in the majority of cases. This should be done before actual extrusion of the implant to avoid any visible scarring. The question of when to reinsert the implant remains controversial. Three months is the most acceptable interval for implant reinsertion.

Deviation/Migration: This may occur as a result of a pocket that is created which is too large or from imprecise sculpting of the implant, or from hematoma formation on one side, or from trauma to the nose. The surgical causes can be minimized by using the 3D high definition system to create an accurate pocket and implant asymmetries can be diminished by sculpting the implant with Dr. Rizk powered sculpting system instead of the older manual system. Trauma issues must be discussed with patient ahead of time so they can understand the importance of protecting the nose for 1 month from any trauma after the surgery until it is settled in. Deep dissection of a precise pocket and accurate shaping of the implant are important to avoid a superficial movable implant. Occasionally, a second operation may be needed to reposition the implant.

Actual Extrusion of Implant: This occurs more with silicone and less so with cartilage implants or medpor. Most commonly, extrusion will occur in the tip area or incion sites at columellar rim. If extrusion occurs it is not advisable to repair the skin defect, because the skin has thinned out, and there will be increased tension on closure because of loss of tissue. Dr. Rizk prefers to remove the implant and allow the necrosed area to heal by secondary intention. After healing, a revision of the resulting scar can be achieved either by excision of the scar with primary closure or the use of flaps or grafts.

In conclusion, autografts (CARTILAGE) CONTINUE TO BE THE IDEAL GRAFT because of the low infection and resorption rates, as well as lack of rejection. However, sometimes the need for a distant cartilage or bone donor site limits their use. Rib grafts have the additional risk of possible warping, although low with certain preparation of the rib graft. Warping can still occur with rib grafts at a low rate of 3 percent. Medpor does not warp, is permanent, has a low infection and extrusion rate if placed in a deep pocket. Ear cartilage and septal cartilage are excellent material if they are firm. Sometimes, in Asian noses, ear and septal cartilage are too weak and do not provide enough support, but sometimes they are good and that depends on the nose. These autogenous cartilage donor sites include rib, septum, or ear. Septum or ears have a lower complication risk than autogenous rib which can cause a lung collapse. An alternate source of cartilage is banked rib cartilage which is excellent as well and does not involve a second surgical site. It is rib cartilage donated and treated in FDA approved methods which have a low resorption, warping, or infection rate. With septal cartilage, it is available from the same operative field, has low donor site morbidity, and is easily carved and contoured, however; there is often insufficient quantity for dorsal implants. Often, Dr. Rizk will have enough septal cartilage to use for tip implants only.

Conclusion
Asian patients present with several common characteristics of the nose that must be addressed to achieve aesthetically pleasing and natural postoperative results. A variety of graft materials have been used to address these patients, including some which are natural cartilage and other synthetic implants, like medpor. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant. It is important for the patient to discuss the advantages and disadvantages of each type of implant and come to an agreement to which is the best for you.