Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 7479

The complications of giant titanium implants in nasal reconstruction

Ullas Raghavan, Nick S. Jones*
Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital, Nottingham NG7 2UH, UK
Received 1 October 2004; accepted 17 May 2005

KEYWORDS
Implants; Titanium; Nasal reconstruction; Autologous; Alloplastic; Extrusion

Summary We present two cases where a large titanium implant has been used in nasal reconstruction without regard to the basic principles and current philosophy in reconstructive techniques. A full thickness nasal defect requires reconstruction with an inner lining, scaffolding and external skin. Autogenous grafts are preferable particularly when they are used for support or their insertion creates tension on the overlying soft tissue. We report serious complications that result from a disregard to these basic principles in two patients following the insertion of giant titanium nasal implants along with their management. Crown Copyright q 2005 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. All rights reserved.

In nasal reconstruction where there is a full thickness defect this needs to be replaced with a lining, a scaffold and an external layer of skin. The overlying skin should ideally be of the same quality in terms of thickness, and degree of sebaceous tissue and colour, as the skin that is being replaced. Any defect in the framework needs to be corrected by providing a suitable scaffolding for its overlying and underlying soft tissue. A number of autogenous and alloplastic materials are available to replace cartilage and, if necessary, bone.1 Autogenous cartilage grafts are considered to be the rst choice2 and are the standard by which others are
* Corresponding author. Tel.: C44 115 9249924; fax: C44 115 9709748. E-mail address: nick.jones@nottingham.ac.uk (N.S. Jones).

judged.35 Cartilage grafts are pliable and give structural support4 although they often need to be laminated to provide strength. Alloplastic materials are associated with extrusion and infection in approximately 5% or more.68,12 The ideal implant should be biocompatible and not elicit an inammatory reaction, degrade, transmit diseases or act as a carcinogen and should be resistant to infection.2 Since the 1920s stainless steel (an alloy composed primarily of chromium and nickel) has been used by some workers.3 More recently Vitallium (an alloy of cobalt, chromium and nickel) or titanium (almost entirely composed of elemental material) has been used as an alloplastic graft.3,9 An alloplast often induces a layer of brous tissue separating the implant from the surrounding tissue. 10 The

S0007-1226/$ - see front matter Crown Copyright q 2005 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. All rights reserved. doi:10.1016/j.bjps.2005.05.011

The complications of giant titanium implants in nasal reconstruction thickness and cellular composition of this brous capsule depends on its biocompatibility.10 All implants evoke acute or chronic inammation depending on their porosity as well as the stability and inertness of the material used.9 Long term chronic inammation is normally seen when the implant slowly leaks its low molecular weight components.9 Titanium and Vitallium have a unique ability to facilitate osteointegration or direct bone adhesion and ingrowth in perforated implants.3 When properly stabilised, titanium bonds to bone on a molecular level without developing intervening brous tissue.10,11 Titanium mesh was introduced in 1968 for the semi-rigid xation of maxillofacial injuries during the Vietnam war.12 Rigid miniplates, whether made of stainless steel or titanium, are widely used in facial trauma.12 One of the main concerns in the use of alloplastic materials is the change they can cause to the overlying skin and soft tissue if the patient reacts to the implant. If this happens the patient is left with atrophic skin, telangectasia, discolouration, excessive scar tissue formation and deformity.13 Miniplates are not routinely removed unless they become infected, loose, induce a foreign body reaction or are associated with unexplained pain.12 Recent studies have advocated the use of titanium mesh without any internal lining.10 In the latter study eight patients had a titanium mesh implanted for orbital and midfacial reconstruction with the implant exposed to the naso-oral-pharyngeal area and the paranasal sinuses. They demonstrated budding of soft tissue through the mesh and then it became lined by mucous membrane with eventual incorporation of the implant although the reported follow-up of each patient was limited.10 This report appears to have encouraged other workers to try and use or extend the role of titanium implants in nasal reconstruction. We present two patients who had giant titanium implants inserted for nasal reconstruction in another hospital with serious sequelae. We describe these problems and advocate avoiding the use of giant titanium implants for nasal reconstruction in preference to autogenous material and illustrate how this can be achieved by the reconstruction in one of these cases.

75

Figure 1 Plain radiograph of the titanium implant xed to the frontal bone and maxilla.

lithographic model was used to prepare a titanium nasal implant (Figs. 1 and 2) that was inserted through a bicoronal ap and midfacial degloving.

Case 1
A 35-year-old Caucasian lady had nasal trauma following a road trafc accident 5 years previously. Microplates were used to x the nasal bones with an unfavourable aesthetic result. A stereoscopic

Figure 2

The titanium implant after removal.

76 The implant was covered in two layers of temporalis fascia. No internal vascularised layer was used. The postoperative results were disappointing and another ve operations were required as the soft tissue contracted over the implant, which started to protrude through the tip of the nose. The tip of the implant was cut sequentially until the soft tissue had retracted. As a result of the appearance of the nose the patient became a recluse. Three years after the implant was placed it was seen projecting into the left nostril with mucopus around it and she was referred to our centre for further management. On examination the nasal tip was turned up forming a wide nasolabial angle (Figs. 3 and 4). Her dorsal skin showed excessive scarring and telangectasia. Very little residual septal cartilage could be palpated and the titanium implant was seen projecting into the left nostril with pus exuding around it (Fig. 5). Revision surgery was discussed with the patient. A considerable amount of counselling was done with the patient and her family before embarking on surgery in order to temper her cosmetic expectations and advise her on the risk of infection of any graft. During her surgery pus and granulation tissue was found around the implant site along with scar tissue. The implant was found fractured from the screws attaching it to

U. Raghavan, N.S. Jones

Figure 4

Frontal view after titanium implant.

the maxilla on the left. The implant was removed through an inverted V shaped incision which allowed the tip of the nose to be rotated, but importantly it was also necessary to divide the internal lining so that the inside could be rotated downwards as well. After the titanium implant had been removed there was a very large defect. Microbiological swabs were taken before it was

Figure 3

Lateral view after titanium implant.

Figure 5 The titanium implant projecting into the nasal cavity with mucopus exuding around it.

The complications of giant titanium implants in nasal reconstruction thoroughly irrigated with aqueous Betadineq. The healthy part of her left upper lateral cartilage was preserved but there was no identiable right upper lateral cartilage. Posteriorly based septal aps were rotated to recreate the inner lining. The defect was so large that four layers of full thickness costal cartilage were required to ll it. These were secured together and to surrounding periosteum with 4/0 prolene. A paramedian ap and bilateral cheek advancement aps were used for the external layer. A second procedure 5 weeks later divided the pedicle of the paramedian forehead ap and the septal aps (Figs. 6 and 7). The patient was happy with the cosmetic result after 2 years follow up.

77

Case 2
A 59-year-old Caucasian lady suffering from hereditary haemorrhagic telangectasia developed frequent torrential epistaxis for which she had received nasal packs on many occasions. Fifteen years ago she had had her nasal septum excised in an effort to reduce the bleeding points. Following this she developed columella collapse. Her troublesome epistaxis continued and during one severe

Figure 7

Postoperative frontal view after 26 months.

Figure 6

Postoperative lateral view after 26 months.

episode it was decided to ligate bilateral external carotid arteries and both anterior ethmoid arteries. After a remission of a few months the epistaxis recurred and again required multiple nasal packs. She developed left nasal vestibular stenosis. An attempt was made to correct this with a nasolabial ap that failed. A titanium scaffolding without an internal lining was then used to support her nose (Fig. 8). Meanwhile she developed a palatal perforation following an attempt to cauterise a bleeding point on the palate. The titanium implant gradually became exposed through the skin over the right medial canthus (Fig. 9). Eight operations were done to cover the implant at the exposed site with local rotation aps but all attempts failed. Many attempts were made to correct her columella, tip of nose and her collapsed ala. She was referred to this centre for further management. Examination revealed a collapsed nasal dorsum with an exposed implant that was visible internally as well as externally through a skin defect near the right medial canthus. The zygomatic branch of the facial nerve on the right side was weak. After detailed discussion with the patient it was advised that one option was for her to have total rhinectomy with a nasal prosthesis. The senior author has described how to reconstruct the nose in

78

U. Raghavan, N.S. Jones

Figure 8 Radiograph of the titanium implant used for nasal reconstruction.

the absence of any nasal bones or septum14 but advised against this as she had received nearly 100 units of blood during various transfusions for her hereditary haemorrhagic telangectasia and has developed antibodies to many blood antigens. A rhinectomy and prosthesis would provide a cosmetically acceptable nose and allow good exposure to control epistaxis if necessary. The patient has decided to defer any decision and at present camouage is being used to disguise her implant that is becoming progressively more exposed.

Figure 9

Exposed titanium implant.

Discussion
Titanium is a widely accepted alloplastic implant used in facial trauma. However, the preferred graft material is autologous cartilage.3 Septal cartilage, if enough is available, is ideal.14 Following severe nasal trauma a sufcient amount of good quality septal cartilage is not always available. Auricular cartilage is another excellent choice8 but it requires laminating if it is to provide any structural support. Costal cartilage is available in quantity although it extends surgical time, leaves a scar on chest and causes local discomfort for several days after surgery even if marcaine intercoastal nerve blocks are used. The usual problems associated with

autogenous grafts are technical on the part of the surgeon2 who must spend time dissecting any soft tissue and precisely sculpturing the graft.13 Alloplastic materials may be used when autogenous materials are insufcient to ll the defect. Whilst they are readily available, and less time is required to fashion the pocket and sculpture the implant they are more prone to infection, scarring and produce overlying telangectasia.1,2,13 In case 1, a giant custom made titanium implant was used to reconstruct a large nasal defect. However, this implant was not provided with a vascularised internal lining and placed a great deal of pressure on the overlying soft tissue envelope. Whilst there is one report that has shown that meshed titanium can become incorporated in soft tissue11 there is little evidence to support this technique. The use of solid titanium without being incorporated within vascularised tissue is doomed to become infected. Even within a vascular envelope titanium is likely to protrude through soft tissue if it exerts any pressure on it. Supporting the nasal tip with a metallic implant would also give an unnatural feel as well as compromising the vitality of the overlying skin. We advise against the

The complications of giant titanium implants in nasal reconstruction use of titanium for nasal reconstruction in preference to autogenous material as it is less likely to become infected, induce a foreign body reaction and be rejected, and is more likely to become incorporated as well as provide a more natural feel. Case 2 adds further to the statements made above and demonstrates how the external soft tissue had undergone ischemic necrosis to expose the implant. Autogenous grafts are the graft of choice in nasal reconstruction. If alloplastic implants are used as scaffolding they should be protected both internally and externally by vascularised soft tissue in order to prevent extrusion and infection. If an implant is placed in a soft tissue envelope excessive tension should not exist or it is likely to become exposed, particularly if it is used for support rather than to disguise a defect. Whilst titanium mesh implants allow soft tissue to grow through the mesh and integrate with the implant they have a higher infection and extrusion rate than autogenous grafts. Solid titanium implants as described here should not be used in nasal reconstruction.

79

References
1. Bikhazi NB, Chow AW, Maas CS. Nasal reconstruction using a combination of allopladtic materials and autogenous tissues: a surgical alterantive. Laryngoscope 1997;107:108693.

2. Porter JP. Grafts in rhinoplasty alloplastic vs autogenous. Arch Otolaryngol Head Neck Surg 2000;126:55860. 3. Mass CS, Monihan N, Shah SB. Implants in rhinoplasty. Facial Plast Surg 1998;13:27990. 4. Collwan SS, Fix RJ, Moore JR, Vasconez LO. Nasal cartilage graft: more than a decade of experience. Plast Reconstr Surg 1997;100:5471522. 5. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin Otolaryngol 1998;23:20917. 6. Clark JM, Cook TA. Immediate reconstruction of extruded alloplastic nasal implants with irradiated homograft costal cartilage. Laryngoscope 2002;112:96874. 7. Jordan DR, Onge PS, Anderson RL, Patrinely JR, Nerad JA. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology 1992;99:16008. 8. Anderson PA. Grafts in rhinoplasty; autogenous grafts are superior to alloplastic. Arch Otolaryngol Head Neck Surg 2000;126:3612. 9. Silver FH, Maas CS. Biology of synthetic facial implant materials. Facial Plastic Surg Clin North Am 1994;2:24153. 10. Schubert W, Gear AJ, Lee C, Hilger PA, Haus E, Migliori MR, et al. Incorporation of titanium mesh in orbital and midface reconstruction. Plast Reconstr Surg 2002;110:10229. 11. Constantino PD, Friedman CD, Lane A. Synthetic biomaterials in facial plastic and reconstructive surgery. Facial Plast Surg 1993;9:115. 12. Patel MF, Langdon JD. Titanium mesh osteosynthesis: a fast and adaptable method of semi-rigid xation. Br J Oral Maxillofac Surg 1991;9:31624. 13. Toriumi DM. Autogenous grafts are worth the extra time. Arch Otolaryngol Head Neck Surg 2000;126:5624. 14. Brackley PTH, Jones NS. The use of a periosteal/forehead ap with sandwiched conchal cartilage grafta novel approach for nasal reconstruction in the absence of a nasal septum. Plast Reconstr Surg 2002;110:8315.