Guide to Nasal Implants
What kind of implants does Dr. Rizk use?
Dr. Rizk prefers the custom-sculpted Medpor implant in thick skin ethnic noses. The Medpor integrates better than silicone and Dr. Rizk customizes the implant during the procedure with his powered dermabrading system to perfectly fit into your nose creating smooth rather than visible sharp or pointy edges. This customized implant integrates by tissue ingrowth into the implant and therefore stabilizing it. The need for an implant In ethnic noses arises when there is poor quality cartilage in the septum and ear characteristic of ethnic patients' cartilage - though there are some cases where Dr. Rizk has used patient's own cartilage successfully.
What is a nasal implant?
A nasal implant is either a synthetic biocompatible material or a biological material processed through FDA approved methods to be used as implants. Examples of synthetic implants are medpor , silicone, or Gor-tex. Examples of biologically derived implants are irradiated rib cartilage from a rib bank or Alloderm (collagen like soft material used to thicken nasal skin). Biological implants may absorb (shrink) to some extent with time but synthetic implants do not shrink or change with time. Synthetic implants are used and have been tested not just for cosmetic or reconstructive purposes in the nose but are used for reconstructive purposes in other parts of the face, body, and joints with a long record of follow up.
Why not use natural "grafts" all the time?
It is also possible in some patients to use natural “grafts”-there are advantages and disadvantages to synthetic implants versus natural grafts. Natural “grafts” sometimes absorb or deteriorate with time, whereas, synthetic implants do not deteriorate. Rib, septum, and ear cartilage have varying degrees of absorption with time. Natural "grafts" sometimes warp (twist) over time and rib cartilage has the higher risk of warping with time. Dr. Sam Rizk uses both natural grafts and synthetic implants and sometimes uses a combination of both to achieve the best outcome with maximal support and definition.
Who is a good candidate for nasal implant use?
According to Dr. Sam Rizk, a New York facial plastic surgeon and nose specialist, healthy non-diabetic patients who are non-smokers are the best candidates for nasal implant use because they are the least likely to encounter an infection and achieve an excellent outcome. Patients with thicker skin also tend to be better suited for implants as the thicker skin provides better coverage and protection of the implant. Patients with thin skin may require a thickening graft of Alloderm or temporalis fascia between the synthetic implant and the patient’s skin. Interestingly, the patients that need implants the most such as African Americans or Asians tend to have thick skin.
Which patients are not good candidates for implant use?
Dr. Sam Rizk explains that it is very important to select patients carefully for synthetic implants to obtain a successful long term result and decrease the risk of infection, movement or extrusion. Dr. Rizk does not recommend using implants in smokers, patients who use illicit drugs in the nose such as cocaine, diabetic patients, or patients with a reduced immunity status. Smokers, in particular, tend to have a higher risk of infections of the implants and subsequent need for removal.
Why use nasal implants?
Nasal implants are used to correct nasal deficiencies in the dorsal area (bridge of nose) as well as many other areas of the nose including the tip or the sides. They may be used to give height or definition to a flat nose or tip in an ethnic African American or Asian rhinoplasty or they may be used to correct a collapse on one side of the nose to make it look straighter. An implant may also be used to support a drooping nasal tip. Implants are frequently used in revision rhinoplasty where too much cartilage was removed from a previous rhinoplasty.
How are the implants shaped?
Nasal implants come in varying sizes and shapes for the tip and dorsum (bridge of the nose). However, Dr. Sam Rizk believes it is important to sculpt and customize the implant to the patient and has developed a method for customizing implants using powered sanding tools (see Plastic Surgery Practice publication in the media section of this website) rather than simply using a surgical knife to sculpt the implant. Powered methods of sculpting the implants are more precise and eliminate the sharp edges often created with the surgical knife.
Why not use one’s own (autogenous) material in the nose all the time?
Dr. Sam Rizk, a New York City facial plastic surgeon and nose specialist, explains that autogenous grafts (from one’s own body) can be used in the nose either from the septum or ear or from other sources. Dr. Rizk frequently uses autogenous cartilage in the nose. However, and especially in ethnic noses, sometimes, one’s own cartilage is too soft and weak to provide the needed support or definition to the bridge and tip of the nose. Sometimes Dr. Rizk uses autogenous cartilage grafts in combination with implants to give the needed support and definition. Also sometimes in severe saddle nose deformities in revision rhinoplasty or in traumatic noses, one’s own cartilage is not thick enough to give the needed height in a nose. In Asian and black rhinoplasty, the patient’s septum and ear cartilage tends to be thin and weak and inadequate for the support and definition needed in these noses to support their thicker skin. One’s own cartilage can also absorb (shrink) with time and may warp (twist) as well with time, whereas synthetic implants do not absorb or warp.
Why not obtain rib cartilage if ear or septum cartilage is not adequate instead of synthetic implants?
Dr. Sam Rizk further explains that going into the chest to obtain rib cartilage has many risks and the cartilage obtained may also warp (twist) or absorb (shrink) with time. A dropped lung, called pnemothorax, is one of the more dangerous risks of obtaining one’s own rib cartilage if the lung pleura is breached, in addition to a second surgical site scar in the chest area with potential for infection and poor scarring.
What are the risks of using nasal implants?
Dr. Rizk has excellent success using medpor implants in healthy individuals who do not smoke. Medpor implants tend to integrate in the nose better than silicone and are less prone to movement than silicone. Tissue ingrowth with medpor decreases medpor implant movement. However, implants in general, have a risk of rejection, infection, movement, and may occasionally need to be removed. Infection or extrusion risks vary between the various implants. Dr. Rizk decreases these risks by using implants on healthy nonsmoking patients with thicker skin. Their advantage as opposed to natural autogenous grafts is a lack of absorption (shrinkage with time) and their strength to provide support and superior definition. The advantage of autogenous (one’s own tissue) grafts is a low rate of rejection and infection.
What are the various types of synthetic implants available?
Below, Dr. Sam Rizk discusses different types of nasal implants, both from synthetic and biological sources.
- Nasal silicone implants - sometimes called silastic implants. These implants are made of medical grade solid silicon and are nonporous. Solid silicone implants are not used by Dr. Sam Rizk because of their extrusion or movement with time. Dr. Rizk believes that the nose does not integrate silicone implants well, and rather forms a capsule around the implant. This fibrous capsule allows movement of the implant over the nasal dorsum where it can move or shift in that capsule. Solid silicone implants have been used since the 1950’s. They are usually easily removed. This implant is very common in Asian countries such as Japan, Korea, and China. Complication rates vary significantly in the literature from between 4 percent- 36 percent. Extrusion and need for removal can sometimes occur as long as 20 years after the initial procedure.
- Medpor (porex)-implants - a highly biocompatible polyethylene implant made of a lightweight porous material. This implant has been used for many years in the nose and face and is immobilized (moves less than silicone) by ingrowth of the body’s tissue into the porous areas of the implant. Dr. Rizk favors this implant in many thick-skinned ethnic patients to achieve superior definition and support. Dr. Rizk does not use this or other implants in thin skin patients for reasons of visiblility and increased potential for extrusion. Medpor is Dr. Rizk’s first choice in alloplastic materials if autogenous cartilage is inadequate or not sufficient for support and definition. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant. Because of its porous texture, it allows tissue to grow and incorporate the implant, which makes the implant less likely to shift or move. This ingrowth prohibits shifting. Dr. Rizk sculpts and customizes the shape and size of the implant to the patient. These implants have been widely used for facial repair in the nose, in the eye, in facial trauma and for correction of congenital malformations of the ears. Its incorporation makes it shift less but it also makes it more difficult to remove.
- Gor-tex (ePTFE) - expanded polytetrafluroethylene- biocompatible implants are less porous than medpor but more porous than silicone. They allow some tissue integration, and are not as firm as silicone. This implant is too flexible and not firm enough for the nose, according to Dr. Rizk, and is not ideal for the dorsum (bridge) augmentation. The nasal bridge is normally more solid than the Gor-tex implant. It may also be sculpted and customized although not as easily as the Mepor. Gor-tex comes in sheets and often needs to be layered.
- Autologous options using your body’s own septum, or ear (conchal) cartilage are also an option and may be used depending on individual patient.
- Homologous irradiated rib cartilage (from a rib bank) - also an excellent option-and used also by Dr. Rizk but as with human-derived products have a certain percentage of warping (twisting) and absorption with time. Processed through FDA approved methods and provide an excellent source of cartilage.