Choosing a Grafting Material for Revision Rhinoplasty
There are many choices of grafting materials when considering revision rhinoplasty. Allografts are obtained from your own body and can include septal cartilage grafts, ear cartilage grafts, and rib cartilage grafts. Sometimes donor rib cartilage from a cadaver (that has been irradiated) may be used as well. Foreign material (implants) are also available in silicone/sialastic, ePTFE (Goretex), and medpor.
Each material has its advantages and disadvantages. I base my decisions on what is best for my patients on many factors. This includes, but is not limited to your age, what kind of grafting is necessary, where the grafting needs to be performed, and your preference/expectations/desires.
Remember that not all surgeons perform rib cartilage grafts or some of these other grafts, and each surgeon will have their preference and their reasons for it. You should obtain several consultations in order to determine who and what you feel most comfortable with. Having this information will help you make an informed decision that is best for you.
Natural cartilage is a good grafting material
The benefits of using the patient's own cartilage in nasal reconstruction are significant. There is no risk of transmitted virus (known or unknown), less risk of infection/extrusion/overlying redness. Rib cartilage can be shaped to obtain a very good reconstruction.
Implant materials for Revision Rhinoplasty
In the tip, it is generally best to use autologous material: septal or ear cartilage, as implants in this area tend extrude or look unnatural. In primary rhinoplasty in Asia silicone tip/bridge implants have been used with some success but this could be risky with thin skin in a revision rhinoplasty. Personally, I prefer gortex to silicone in the bridge/ I find it more natural looking and feeling and have had no problems with mobility or extrusion/ infection.
Implant Materials And Reabsorption
Each material has distinct benefits and disadvantages. I have a strong preference towards autologous (your own body's tissues) then the use of a foreign implant. Autologous tissues have better tissue integration and less chance for infection than a foreign body. The downside of autologous implants is that the patient has to have a donor site (i.e. rib or ear cartilage) to recover from as well.
Foreign bodies have a higher risk of infection and extrusion than autologous implants. Irradiated rib is a good choice in patient's who are older and can not use their own rib cartilage. Irradiated rib does not perform well in the tip area or in a supportive mechanism for tip projection. Irradiated rib is "non-living" cartilage, making it quite different than patient's own rib.
For more information about costal cartlage and other grafts see link below.
Which dorsal augmentation material to choose?
Silicone is not a popular product in the U.S. due to concerns regarding extrusion and infection. Certainly, if you require improvement to your nasal tip support sticking with cartilage would be ideal. Autologous (your own) cartilage is the ideal source for this and depending on how much augmentation is desired septal, ear or rib cartilage are options. In experienced hands autologous cartilage has been shown to be very durable with excellent longevity. An important point regarding using your own rib cartilage is that its use is age dependent. The cartilage calcifies as we age making it more difficult to use during surgery. Irradiated rib cartilage has also been used with success by other surgeons (Russell Kridel recently published a 20-year review on his results), however.
What Material to Choose for Revision Rhinoplasty?
I would recommend staying away from any alloplastic material such as silicone. In my years of doing revision rhinoplasty, I have had to remove quite a few silicone implants due to problems with contour and infection. Irradiated costal (rib) cartilage is not a poor choice for rebuilding your bridge and tip as long as your surgeon is experienced in its use. Autologous costal cartilage is perhaps a better choice since some reports indicate less resorption and warping when compared to irradiated sources of cartilage. The tradeoff is having an incision along your chest with more postoperative pain and a chance of possibly puncturing your lung. I would focus more on deciding between the irradiated costal cartilage and autologous costal cartilage.
Irradiated rib grafts for rhinoplasty
I would caution against using an artificial material such as silicone along with irradiated rib. Irradiated rib has been shown to be long lasting, with a low risk of resorption or warping. A recent landmark study by Dr. Kridel et al showed excellent results over 20 years using irradiated rib grafts: Long-term Use and Follow-up of Irradiated Homologous Costal Cartilage Grafts in the Nose Russell W. H. Kridel, Faramarz Ashoori, Edmund S. Liu, Carol G. Hart. Arch Facial Plast Surg. 2009;11(6):378-394.
Rhinoplasty with Implant and Rib Graft
There's a lot of missing information here. How many surgeries have you had? What was done to the nose? What are your remaining concerns and how significant are they? What septal or ear cartilage do you have left? After a good consultation or two or three, you should have a good idea of what will work well for you. I have been favorably impressed with dorsal implants if they are placed properly. I have combined these with autogenous cartilage grafts many times with no problems. However, you need to match the operation to the patients' problem and their unique concerns. I would go for septal cartilage, followed by ear cartilage and would use rib cartilage as my last resort. I have little experience with irradiated cartilage but the few times I have seen it used there was almost complete reabsorption of the graft. Your anatomy and aesthetic desires will dictate what will work best. Good Luck
Revision rhinoplasty surgery is a rather difficult procedure, performed best by a talented, skilled and experienced Rhinoplasty surgeon. You need to be able to trust your surgeon as to the best material to use. In general ideal choice in revision rhinoplasty is autologous cartilage ( septal, ear or rib). These grafts, if well executed, tend to have the lowest rate of resorption and distortion. Silicone implants in revision rhinoplasty typically do not lead to a satisfactory result. Irradiated cartilage can be used in some cases, with less predictability.
Irradiated rib cartilage is a poor choice for rhinoplast
Irradiated cartilage will resorb in time and will warp if there is any pressure on its structure before the resorption occurs. Septal and ear cartilage are better choices. For structural support, I like a very thin sheet of medpore that is easly tailored to the needs of the patient and comes out of package.