Reconstruction of the Major Saddle Nose Deformity Using Composite Allo-Implants

Abstract

The major saddle nose deformity leaves a patient with an obvious aesthetic deficit as well as an equally disturbing functional handicap. Reconstructing the collapsed dorsum and tip and simultaneously restoring nasal function present a formidable challenge which has elicited a wide variety of solutions ranging from the use of a toothbrush handle to split calvarial grafting. As Murakami et al pointed out, the "variability exists to a large extent, because the saddle nose deformity is not a single entity but rather a spectrum of abnormalities." Attempts to categorize saddle nose deformities are useful; however, they often lack the simple impact and clarity of the pre-operative photograph. Moreover, the categorizations have not led to a uniform approach to this complicated problem. Nevertheless, Tardy's classification of minimal, moderate, and major saddle nose deformities provides a helpful framework for discussion of reconstructive options. Minimal deformities demonstrate a supratip depression of 1 to 2 mm and are easily corrected with cartilage or fascial overlays. Moderate saddle nose deformities are characterized by a significant loss of dorsal height as well as columellar retraction and broadening of the bony pyramid. A major deformity demonstrates "all of the stigmata of the moderately saddled nose, only to a more marked degree." In Tardy's opinion, an open approach may be warranted in these cases. We offer one solution to the major saddle nose deformity using a composite allo-implant of porous high-density polyethylene (PHDPE) (Medpor surgical implants, Porex Surgical, Inc., College Park, GA) and purified acellular human dermal graft (Alloderm, Life Cell Corp., TX.). While we readily admit that autogenous tissue is the preferred grafting material, we have encountered patients in whom this is not an option. Major saddle nose deformities typically require more augmentation than stacked septal or auricular cartilage can provide. Additionally, in patients seeking revision rhinoplasty, sufficient donor septal or auricular cartilage is often lacking. Resorption of irradiated cadaveric rib grafts has led us away from this material. Split calvarial bone grafts are our next recommendation for these patients; however, many patients refuse this option. In these patients we have turned to a composite allo-implant of PHDPE and acellular human dermal graft for reconstruction of the collapsed dorsum and tip.

Comparison of Autogenous Cartilage, Acellular Dermis, and Solvent-Dehydrated Pericardium for the Prevention and Correction of Dorsal Nasal Irregularities: An Experimental Study

“…AlloDerm is a commercially available product that is harvested from cadaveric skin, frozen, and dried to obtain acellular dermis [1,7,[20][21][22]. Donor skin samples are tested for bacterial or fungal infections according to the U.S. Food and Drug Administration (FDA) rules.…”

“…ADM integrates and reshapes after implantation. AlloDerm has been used for various clinical procedures such as a dermal replacement for burns, gingival grafts in periodontal surgery, augmentation materials, and reconstruction of nasal septal perforations [1,7,[20][21][22]. It has been widely used for lip augmentation and filling of the nasolabial groove in aesthetic surgery with promising results, but the follow-up periods are still believed to be short [1].…”

“…It has been widely used for lip augmentation and filling of the nasolabial groove in aesthetic surgery with promising results, but the follow-up periods are still believed to be short [1]. It is also used for the nasal dorsum with satisfactory results [1,7,21]. SDP (solvent-preserved, gamma-sterilized bovine pericardium; Tutoplast, Tutogen Medical, West Patterson, NJ, USA) is an allograft used for orbital reconstruction, ophthalmic surgery, tympanoplasty, duraplasty, closure of nasal septal perforations, suspension procedures in facial palsy, filling of parotidectomy defects, hernia repairs, corporoplasty, and Peyronie's disease [23][24][25][26][27][28][29][30][31].…”

Use of Porous Polyethylene Implants in Nasal Reconstruction

“…It has been used in dorsal implantation, 22,23 revision rhinoplasty, 24,25 reconstruction of traumatic nasal deformities 26 and corrective surgery for the bulbous tip. 27 It has had variable complication rates reported ranging from 2.7 to 18%.…”

Three Meetings in Athens June 20–23, 2001 Astir Palace Vouliagmenis Hotel

“…8 Tremendous industrial resources are invested in alloplastic materials in hope that they might become the new implant of choice for structural grafting; however, no single material has yet surfaced with wide acceptance for safety, host compatibility, and longevity. 9,10 The predicament of insufficient grafting material during nasal reconstruction remains.…”