Author's personal copy

Operative Techniques in Otolaryngology (2007) 18, 315-323

Complications using grafts and implants in rhinoplasty

Guy Lin, MD, William Lawson, DDS, MD

From Department of Otolaryngology, Mount Sinai School of Medicine, New York, New York.

KEYWORDS Understanding the use of autologous, homologous, and alloplast materials for grafting and implantation
Rhinoplasty; purposes has become a necessity in the armamentarium of the rhinoplasty surgeon. This article reviews
Implants; the indications and relative incidences of complications associated with the use of different grafting and
Grafts; implant materials in rhinoplasty.
Complications; © 2007 Elsevier Inc. All rights reserved.
Revision rhinoplasty;
Alloplast

The focus of rhinoplasty is to achieve nasal balance and
establish harmony with the face while preserving a func-
tional nasal airway. Historically, rhinoplasty was mostly
reductive surgery. The esthetic ideal has shifted to creating
an unoperated look with long-term stability, which is
achieved through a combination of reduction and augmen-
tation techniques, with an emphasis on preservation of the
existing framework of the nose. The nose is also important
for functional reasons, including olfaction, and as a primary
respiratory pathway. Obtaining excellent esthetic results in
rhinoplasty should not be achieved at the expense of losing
functionality in the nose. Understanding the use of autolo-
gous, homologous, and alloplast materials for grafting and
implantation purposes has become a necessity in the arma-
mentarium of the rhinoplasty surgeon. This article reviews
the complications associated with the use of different graft-
ing and implant materials in rhinoplasty.
The indications for the use of these materials include the
correction of traumatic and developmental deformities, es-
thetic enhancement, and to improve nasal functionality.
Graft and implant materials are used primarily to maintain
or strengthen the structural framework, to provide contour
or camouflage for defects and to restore the nose to an
esthetic ideal. The ideal graft or implant material is biocom-
patible and possesses physical properties and long-term
stability devoid of complications (Table 1). The goal of the
rhinoplasty surgeon is to use a graft or implant without
complications, and simultaneously achieve long-term pa-
tient satisfaction. There are 3 broad categories of graft and
Address reprint requests and correspondence: Guy Lin, MD, 210 E
86th St, 9th Floor, New York, NY 10028.
E-mail address: guylinmd@yahoo.com.
1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2007.09.004
implant materials that are currently available for rhino-
plasty: autografts (derived from the patient’s own tissues);
homografts (derived from tissues obtained from a different
donor of the same species); and alloplasts (implants that are
either semisynthetic or entirely synthetic).
Autografts
Autologous grafting materials include cartilage, bone, skin,
and fascia (Table 2). The main limitation of autologous
grafting materials is availability. When insufficient septal or
auricular cartilage is available for grafting, the reconstruc-
tive surgeon is often forced to choose an alternative donor
site, or another material.1
Cartilage
Cartilage is nearly the ideal implantation material by its
excellent biotolerance, having low infection and extrusion
rates. Cartilage possesses excellent elasticity, resistance,
easy to shape, good vitality even with poor blood supply,
and a minimal resorption rate.2 In the early 1900s, the
unpredictable behavior of homograft cartilage led surgeons
to abandon its use and replace it with autogenous cartilage.
However, the use of autologous grafts was limited by its
warping with time. Peer used diced cartilage to avoid warp-
ing,3-6 and Cottle was the first surgeon to use crushed cartilage
for nasal reconstruction.7 In contrast to osteoblasts, chondro-
cytes have little capacity to regenerate when injured; however,
transplanted cartilage with perichondrium has been shown to
grow, both experimentally and clinically.8-10 Controversy ex-
ists as to the viability of crushed cartilage, with some studies
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316 Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007

Table 1 Properties of an ideal grafting material

Biocompatible physical Resistance to infection

properties
No inflammatory response Cost effective
Easy removal Nonresorbable
No migration No transmission of disease
Easy to modify or mold Noncarcinogenic
Easy to obtain Easy to camouflage

reporting that crushed material remained viable, even lead-

ing to the formation of new cartilage,9 whereas others de-
scribe extensive necrosis of the graft and replacement by
fibrous tissue.8,9 The reduction in average volume retention
of crushed cartilage (69.73%) was found to be statistically
significant as compared with noncrushed cartilage grafts
(94.54%) in animal models.11 Nevertheless, in a clinical
setting, the success rate was found to be relatively
equal.11,12 A major limitation of crushed cartilage is that it
cannot be used to provide structural support.
The use of uncrushed cartilage in the early 20th century
was limited by a lack of knowledge of the etiology of
warping. An understanding of the biomechanical properties
of mature cartilage and control of warping by incisional
techniques resulted in wide clinical application of autolo-
gous cartilage (Figure 1).
Autogenous septal cartilage is generally accepted as the
gold standard of nasal grafting materials. The major disad-
vantage is an insufficient amount present due to prior
trauma, surgery, or infection. Auricular cartilage is an
excellent alternative to septal cartilage in that it is easy to
harvest with a relatively low morbidity. Its curved and
pliable nature can make this a more attractive option than
septal cartilage in situations that require a curved contour.
There is ample literature to support the use of cartilage
grafts with long-term success. Tardy’s retrospective study
of 2000 grafts performed over the course of 17 years con-
cluded that complications were infrequent and often the
result of surgical errors in graft contouring, or inaccurate
Figure 1 Warped autogenous septal cartilage shield graft.
(Color version of figure is available online.)
and imprecise pocket preparation, and not due to the prop-
erties of the graft itself.13 Collawn and coworkers also
reported that, with experience, reoperations decreased from
17% to 10% to 2%.14 Cardenas-Camarena and Guerrero
reported on 930 rhinoplasties requiring cartilage grafting
(64% medial crural strut, 36% tip graft, 19% dorsal) and
reported 84% patient satisfaction after a mean follow-up
time of 51 months, with secondary operations performed in
8% of the patients.15 Ortiz-Monasterio and coworkers used
674 autogenous septal cartilage grafts in 432 primary rhi-
noplasties (56.8% columella grafts; 35.5% tip grafts; 5.4%
dorsal grafts; 2.3% to correct a depressed piriform area),
and noted, after 1 year, graft displacement in 18 patients,
visible resorption in 2, and 4 infections, with 1 requiring
removal.16 The authors did not use postoperative antibiotics
in this study.16 Most authors recommend the use of post-
operative antibiotics with graft placement (Figure 2).
Costal cartilage provides the advantages of a large vol-
ume of graft material with excellent structural support. The
disadvantages are warping and the potential donor site mor-
bidities, including pneumothorax, scar visibility, and chest

Table 2 Grafting materials available for rhinoplasty

Autologous Homologous
materials materials Alloplastic materials
Rigid Rigid Polymers
● Cartilage ● Irradiated ● Silicone
Septal costal ● Polyethylene
Rib cartilage ● Polytetrafluoroethylene
Auricular ● Irradiated (PTFE)
sclera ● Polyesters
Bone ● Polyamides
● Calvarial
● Iliac
● Nasal (inferior
turbinate,
ethmoid)
Soft tissue Soft tissue Resorbable materials
● Temporalis ● Acellular ● Suture
fascia dermis ● Methycellulose (Surgicel)
● Fascia lata (Alloderm) ● Gelfoam (Gelfilm) Figure 2 Infected autogenous septal cartilage graft. (Color ver-
sion of figure is available online.)
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Lin and Lawson Complications Using Grafts and Implants in Rhinoplasty 317

wall deformity. Rib grafts can be harvested as a composite

osseocartilaginous segment. Because of warping, the graft
would be placed under the thicker supratip skin instead of
the thinner soft tissue overlying the nasal dorsum.17 If
warping could be completely controlled, rib cartilage would
be an ideal nasal graft. A decrease in the rate of warping was
achieved by Gunter and coworkers with k-wire fixation.18
Decreased rates of warping of rib cartilage grafts have also
been achieved by careful contouring and removal of the outer
layers of rib cartilage.19 Nevertheless, there are surgeons who
do not use costal cartilage because it is dissimilar in
consistency to nasal tissue, it is difficult to contour, it is
unpredictable in degree of absorption, and it tends to
buckle.14,20 In addition, there is the possibility of transplan-
tation of a growth zone in younger patients that can lead to
unpredictable overgrowth.
Araco and coworkers performed a comparative study using
4 different cartilage donor sites (septum, auricular, composite
auricular, and rib).2 In a study of 62 patients (mean follow-up
of 12 months), the 2 most satisfied groups were from septum
and auricular donor sites, whereas the least-satisfied groups
were the costal and composite graft groups. There was less Figure 3 Infected iliac crest bone graft. (Color version of figure
than 2% risk of resorption and graft displacement in this study. is available online.)
However, the complexity of the reconstruction must be fac-
tored in evaluating grafting outcomes.
Cranial bone grafting, first used in the 19th century, was
reported for nasal reconstruction, in 1983. Advantages in-
Bone clude a donor site with little pain, and a hidden scar. Dis-
advantages include the risk of intracranial injury (cerebro-
There is evidence that membranous bone is more resis- spinal fluid leak, meningitis, and injury to the brain through
tant to resorption than endochondral bone. This is attributed contusion or hematoma formation), depressed scar, alopecia
to earlier revascularization of membranous bone; however, of overlying scalp and limited graft volume.22 In a retro-
because of conflicting experimental evidence, this theory spective review by Jackson and coworkers of 363 patients
has been contested.8 Studies documenting that membranous who underwent calvarial bone grafting, split thickness
bone undergoes less resorption than endochondral bone did grafts were used in 310 pts (85%), and full thickness grafts
not employ rigid graft fixation.8 When rigid fixation is used, in 52 patients (14%).23 The authors reported an absence of
there appears to be no significant difference in resorption resorption in their study, and advocated rigid fixation for
between membranous and endochondral grafts. Membra- excellent long-term results. In this study there were 10
nous calvarial bone develops directly from mesenchymal hematomas and 2 dural penetrations.23 Despite the excellent
condensations without an intermediate cartilage matrix and results reported by Jackson and coworkers, other studies cite
exists only in bones of the cranial vault (neurocranium), 20 to 30% resorption rates of calvarial bone grafts.19,24
facial skeleton, and clavicle. Endochondral bone composes Hematoma and seroma are more common donor site mor-
the majority of the axial skeleton and arises from a preex- bidities, with rarer cases of dural tear and intracerebral
isting cartilaginous framework. The mandible and some hematoma reported.23,25 Although highly popular for a pe-
cranial base bones arise from a combination of membranous riod of time, calvarial bone has fallen out of popularity
and endochondral embryological processes.8,21 because of donor site complications and limited thickness
The most common indication for the use of bone in rhino- (requiring lamination with screw or pin fixation for large
plasty is for dorsal onlay grafting with or without columellar dorsal defects). Inferior turbinate or septal (ethmoid or
support. Regardless of the donor site, the disadvantages of vomer) bone are other options; however, they provide a
bone as a grafting material include its stiff biomechanical limited volume of material and there are no long term
nature and its susceptibility to fracture. Donor sites for autog- outcomes reported. Bone grafts from all sites are well tol-
enous bone grafts include rib, iliac crest, calvarium, and nasal erated, but carry the risk of infection (Figure 3).
septum (ethmoid and vomer). The iliac bone graft has fallen
out of favor because of a significant resorption rate and donor
site morbidity (pain, paresthesia from injury to the lateral
femoral cutaneous nerve, gait disturbance, and the rare occur- Homografts
rence of acetabular fracture).8 Rib bone grafts can be harvested
in lengths of 10 to 15 cm, and then split to double the surface Irradiated costal cartilage
area of the graft. The disadvantages include the potential for
pneumothorax, chest wall depression, and persistent pleuritic Homograft materials are not ideal substitutes for autog-
pain with exercise.8 enous grafting material because of their long-term unpre-
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318 Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 4 Infected homograft cartilage graft. (Color version of
figure is available online.)
dictability and the fear of disease transmission.26,27 Homol-
ogous irradiated costal cartilage (ICC) has been shown to
resorb on long-term follow-up and has the potential to warp.
Schuller and coworkers reviewed 145 patients receiving
ICC to the face (60 to the nose) and, after 3 years mean
follow-up, 5.5% had early complications, 2.2% late com-
plications, with 1.4% showing partial resorption.28 How-
ever, Welling and coworkers later evaluated 42 of Schul-
ler’s original 107 patients and found that, after 10 years, the
absorption rate was 75%. Another major concern with ICC
is the potential for warping.26 Acarturket al encountered
only 1 late warping in 11 cases, and Clark and coworkers in
1/18 patients after 1 year of follow-up.29,30 Kridel and
coworkers on review of 306 ICC implants for nasal recon-
struction found 5% infection, 2.7% warping, 2.7% resorp-
tion, and 0% extrusions after 15 months.31 In addition to
problems with resorption, warping, and bacterial infection
(Figure 4), fear of viral transmission despite extensive ster-
ilization has severely reduced its usage.
Alloderm
Alloderm (LifeCell Corp, Branchburg, NJ) has been used
as a volume filling material as well as for onlaying over
cartilage or other grafting material to soften sharp edges
under the skin. The mean percentage volume persistence of
Alloderm at 1, 3, 6, and 12 months was shown to be 82.8%,
48.3%, 21.9%, and 20.2%, respectively.27 The authors con-
cluded that touch up secondary procedures should be de-
layed at least 6 months after implantation to allow for
stabilization and equilibration of the original implant.27
Gryskiewicz and coworkers reported the use of Alloderm in
25 overresected, thin skinned, graft-depleted noses who
were followed 2 to 8 years, and found the maximum dorsal
augmentation achieved was 3 mm.32 Total resorption oc-
curred in 20% to 30% of patients over the dorsum, and 10%
to 15% over the tip. Overcorrection was advocated, with
partial graft resorption (defined as ⬍50% of graft volume)
found in 45% of the patients studied.32 Temporalis fascia
graft can function as an autologous substitute for alloderm.
The main advantage of temporalis fascia is that it has been
shown to maintain 80% of its original volume.19,33 Unpre-
dictability in the degree of resorption of these materials has
relegated their use to a filler of small defects and a covering
for rigid implants to soften their surfaces under thin skin.
Alloplasts
Significant advancements in biomaterial science and im-
plant technology in the late twentieth century led to the
increased use of implants in facial surgery. Peer com-
mented, in 1954, that most alloplastic implants were being
“buried by one group of surgeons and then being constantly
removed by another group of surgeons after varying periods
of time.”3 Relevance of this statement is seen in the constant
stream of implant materials marketed today.
Alloplast materials can be classified as porous versus
solid. Pores permit tissue ingrowth, with the larger showing
more aggressive ingrowth. Porosity ranges from ⬍20 ␮m to
several hundred micrometers. Implants having small pores
(less than 50 ␮m) are at greater risk for early infection from
the delayed ingrowth of tissue, which recruits immunocom-
petent cells and do not readily admit macrophages. Pores
also allow influx of bacteria. Solid implants include silicone
and porous polyethylene. One advantage of solid implants
over porous implants is that they are easily removed.
An additional classification for alloplast materials is non-
injectable versus injectable substances. Injectable sub-
stances include Bioplastique (Uroplasty BV, Netherlands),
Radiesse (Bioform Inc, San Mateo, CA), and Restalyn
(Medicis Esthetics, Scottsdale, AZ). Fragmentation with
particle formation is also an important factor in determining
its biotolerance. Relatively inert materials between 20 and
60 ␮m can be phagocytized, but ingestion leads to macro-
phage demise, release of several inflammatory factors, and
a foreign body reaction characterized by chronic inflamma-
tion and granuloma formation. Silicone gel and Proplast are
2 examples of alloplast materials that have fallen out of
favor due to this phenomenon.
Silicone
Silicone is a polymer of silicone-oxygen chains cross-
linked by methyl side groups. The degree of cross-linking
determines the physical state of silicone, ranging from a
viscous gel to a rubbery solid.34 The solid implant provides
excellent structural support. This was the first alloplast to
achieve widespread use in facial plastic surgery.19 Nonpo-
rous and surrounded by a thin capsule after implantation,
silicone behaves as a foreign body for the life of the implant.
A major disadvantage of silicone is its notorious mobility
after implantation and its propensity for extrusion if trau-
matized or exposed (Figure 5). Nevertheless, silicone has
been very popular for nasal augmentation in Asian patients.
Its success in this population is aided by the relatively thick
skin-soft tissue envelope over the implant. Silicone grafts
have given good results in primary but not in secondary
 Author's personal copy
Lin and Lawson Complications Using Grafts and Implants in Rhinoplasty
Figure 5 Extruding silastic implant 14 years postoperatively.
(Color version of figure is available online.)
rhinoplasty, where a 42% failure rate has been reported.2
Ham and coworkers reviewed 1500 cases of augmentation
rhinoplasty with silicone and found an 18% incidence of
complications which they attributed to implant design, or
unskillful operative technique.35 All early complications
(6.6%) occurred within 2 weeks, mostly a result of Staph-
ylococcus aureus infections. The majority of the complica-
tions were skin problems, which occurred after 4 weeks
(62.4%), consisting of discoloration, erythema, and overly-
ing skin thinning. The discoloration of the skin did not
improve after removal of the prosthesis. Other commonly
experienced complications included malposition (8.5%) and
extrusion (7.5%), with the tip being the most common site
of extrusion.35
Deva and coworkers reported that 9.7% of 422 patients
of Southeast Asian origin receiving silicone nasal implants
required removal.36 A review by Tham and coworkers of
355 patients revealed a 16% complication rate (160 days
mean follow-up), with 7.9% classified as major complica-
tions requiring removal, or revision surgery.37 The majority
of the implant extrusions occurred more than 1 month after
placement. Similar to Ham and coworkers, the tip was the
most common site of extrusion. A greater rate of extrusion
and infection was associated with larger implants.35,37 The
shape of the implant is important, with L-shaped implants
for dorsal and tip augmentation being the most vulnerable
for extrusion (4-fold greater rate of extrusion than with any
other implant shape).35 In summary, the use of silicone
seems to result in an unacceptably high complication and
dissatisfaction rate based on large retrospective trials. Nev-
ertheless, it is frequently used in Asia, and McCurdy cites
refinements in technique, the design of the implant (softer
elastomer), and patient selection that may be responsible for
a lower rate of complication than generally reported.38
319
Medpor: porous polyethylene (high-density
porous polyethylene)
Several forms of porous high-density polyethylene
(PHDPE) are commercially available (Porecon and Medpor
[Porex Surgical, Newnan, GA]), with pore sizes ranging
from 100 to 250 ␮m. Optimal bony ingrowth occurs with
pore sizes greater than 100 ␮m.39 The increased pore sizes
of PHDPE permit rapid and extensive fibrovascular in-
growth, providing fixation and stability. This has repeatedly
been shown to render it more resistant to infection than
other synthetic implant materials, such as Gore-Tex (W.L.
Gore & Assoc, Flagstaff, AZ).40,41 The rigidity of Medpor
has led to its use primarily for the repair of bony defects and
to augment facial skeletal deficiencies, but it is hard and
difficult to sculpt. Romo and coworkers reviewed 187 pa-
tients (mean follow up time 26 months) implanted with
ultrathin sheets (0.85 mm) of Medpor for nasal augmenta-
tion (dorsum, tip, columella, ala, premaxilla) and found
excellent long term tolerance and a low complication rate
(2.6%).1 The majority of the complications were infections
requiring removal of the implant. Numerous publications
have supported a wide variety of uses of PHDPE in rhino-
plasty.29,41-44 Noteworthy in these studies is the success
reported with this material in secondary as well as tertiary
rhinoplasty procedures.
Wellisz reported on the placement of 27 nasal implants
with a complication rate of 14.8%.44 However, the patient
population in this study represented a higher complexity of
reconstruction, involving trauma, burn, and congenital de-
formities. They recommended that thin implants be used for
rapid vascular ingrowth, no pressure be exerted on the
overlying skin and to use caution with placement of Medpor
in the columella because shearing forces disrupted tissue
ingrowth into the implant predisposing it to exposure.44
Long-term data are lacking with the use of this material.
Gore-Tex: polytetraflorethylene
Polytetraflorethylene (Gore-Tex) is a microporous allo-
plastic compound, with pore sizes ranging from 10 to 30 ␮m
(average pore 22 ␮m), thus allowing for limited tissue
ingrowth and graft stabilization. It is more suitable for
volumetric compensation of smaller defects than for sup-
portive functions. Gore-Tex is manufactured in sheets of
variable thicknesses and can be easily cut, carved, and
sculptured into appropriate shapes and sizes. Histologic
study at 12 months after implantation has shown few his-
tiocytes and giant cells accumulated at the implant site.45 A
mature connective tissue envelope forms around it, with
easy removal still possible.46
Godin and coworkers on review of 309 patients with
nasal augmentation using Gore-Tex (mean follow up of 44
months) found 3.2% of patients had infections necessitating
removal.47 The largest multicenter evaluation of Gore-Tex
use in rhinoplasty was published by Jin and coworkers
involving 853 Asian patients (mean follow-up of 18
months).48 Gore-Tex was used to augment the nasal dorsum
in the majority (96.1%) of patients, with complications
occurring in 2.5%, primarily by infection and requiring
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320 Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
removal.48 Most studies revealed that infection can develop
as long as 3 years after surgery. Complications increased in
revision cases and those with septal perforations.47,48
Herbst and coworkers reported 10 complications (8 in-
fections, 2 soft-tissue reactions) in 466 patients.49 Conrad
and coworkers reported a 3.7% rate of infection, or soft
tissue reaction, in 189 patients (mean follow up of 17.5
months).50 However, Lohius and coworkers reported that 66
patients (mean follow up of 17.9 months) and Owsley and
coworkers 106 patients (over 5 years) experienced no com-
plications.51,52
Supramid mesh (polyamide mesh)
Supramid (S. Jackson, Inc, Alexandria, VA) is an excel-
lent example of why long-term evaluation of implants is
necessary. Supramid is a nylon derivative mesh that, in
1974, was considered a “miracle of modern chemistry” for
dorsal nose enhancement.53 After 10 years, almost all sur-
geons reported the histologic disappearance of polyamide
and abandoned its use.54 Brown described progressive fi-
brous ingrowth into polyamide mesh with fragmentation
and degradation of the implant. Supramid is of historical
interest and serves as a reminder that initial widespread
popularity must be tempered by reliable long-term fol-
low-up data.
Mersilene mesh: polyethylene terephthalate
Mersilene (polyethylene terephthalate [PETP]; Ethicon,
Somerville, NJ) is a woven polyester fiber mesh used pri-
marily for volumetric correction. As opposed to Supramid,
it does not degrade and is stable. A major disadvantage is
the degree of fibroblast ingrowth which makes removal
difficult. Mersilene mesh can be folded, sutured, and shaped
with relative ease, providing a natural feel and early stabil-
ity, but no structural support.19 Colton and coworkers re-
ported a complication rate of 7% (50% requiring removal)
in 113 patients with Mersilene mesh in nasal and facial
augmentation.55 Reported infection rates range between 4 to
9%, with the need for removal in up to 3.5%.19,55-58
Prolene: polypropylene mesh
An additional mesh implant, that has been used exten-
sively by the senior author is Prolene mesh (Ethicon). It has
an established history of excellent biotolerance in vascular
and cardiothoracic surgery. It is available in sheets, with
pore sizes that range between 130 ␮m to 1500 ␮m, facili-
tating rapid and extensive fibrous ingrowth.59 It can be
placed in its native form or as an autoalloplast, where it is
harvested from a donor site where it had been embedded.
After 3 weeks it becomes a solid block which can be carved
to a form for repair of complex nasal deformities. The
autoalloplast is a two-staged procedure with creation of a
donor site behind the ear. When used primarily it can be cut
from the sheet in shapes to fill defects, or laminated for
dorsal augmentation. The layers are sutured together for
stability and contouring. Several high risk patients including
insulin dependent diabetics and immunosuppressed patients
were treated by autoalloplast implantation with successful
long-term results.
Surgicel: methylcellulose
To prevent graft visibility the use of Surgicel-wrapped
diced cartilage (“Turkish Delight”), was developed by Erol.
He reported its use in 2365 patients claiming 0.5% partial
reabsorption.60 However, almost complete absorption of
such grafts has been reported by others.61 The use of mi-
crofibrillar collagen (Avitene; Davol, Cranston, RI) mixed
with autogenous whole blood as a “tissue clay” has also
been described for dorsal contouring in rhinoplasty. Sachs
reported no complications in 58 patients in which ‘tissue
clay’ was used for up to 1 cm of augmentation in rhino-
plasty, claiming only 16% resorption after 3 years of follow-
up.62
Injectable implants
Injectable alloplasts are used for volumetric filling of
small defects. Silicone injection fell out of favor when it
was found to be associated with adverse reactions, including
granuloma formation, chronic inflammation, and other local
tissue changes. Bioplastique is a copolymer composed of
silicone particles dispersed in a resorbable hydrogel matrix.
The gel is eliminated from the body and replaced with
collagen and fibrin within a matter of days.63 Although it is
currently not approved by the Food and Drug Administra-
tion, there are some reports of its use in rhinoplasty.63
Particle size range from 100 to 400 ␮m, with the larger
particle size preventing macrophage ingestion and a subse-
quent inflammatory cascade. There have been more than
100 cases of its use in humans reported in the literature.64,65
Undercorrection is advised to compensate for the fibroblas-
tic reaction and collagen deposition afterinjection of Bio-
plastique. Han and coworkers reported on the use of Resty-
lane, a hyaluronic acid derivative, combined with cultured
autogenous dermal fibroblasts for long-term corrective rhi-
noplasty augmentation. A follow-up time of more than 1
year in 6 patients revealed a volume reduction ranging from
10% to 40%.66 There are also reports of collagen injec-
tion.67,68 The inability to predict and maintain long-term
volumetric correction continues to be the major limitation of
using injectable tissue filler material.
Summary
The complications associated with implant and graft mate-
rials range from common to rarely encountered problems.
Confounding factors, which include surgeon experience,
technical considerations, and patient selection, influence the
success with each material (Table 3). Patients with diabetes,
vascular disorders, and autoimmune disorders are at high
risk for complications. The length of follow-up is also
important in assessing outcomes. The use of autogenous
materials is preferable to nonautogenous material if readily
available from the septum or auricle. In a restrospective
review, Gilbert and coworkers compared the complication
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Lin and Lawson Complications Using Grafts and Implants in Rhinoplasty 321

Table 3 Advantages/disadvantages of autografts, homografts, and allografts

Autografts Homografts Allografts

Advantages Biocompatibility Biocompatibility Strength
Strength (bone) Strength (bone) Elasticity
Ability to contour (cartilage) Ability to contour (cartilage) Durability
Ability to camouflage (fascia) Ability to camouflage (fascia, alloderm) No donor site morbidity
No donor site morbidity Unlimited supply
Unlimited supply Decreased surgical time
Decreased surgical time
Disadvantages Donor site morbidity Increased resorption Higher extrusion rate
Memory (cartilage) Warping (cartilage) Higher infection rate
Resorption Extrusion Higher cost
Limited material Higher infection rate
Warping Higher cost
Displacement Patient confidence with implant safety
Increased surgical time

rates of autogenous cartilage, homograft cartilage, Mer-
silene mesh and Gore-Tex.69 The infection rate with the use
of autograft and homograft material was 0%, but was 25%
with Mersilene mesh, and 6.7% with Gore-Tex.69 The in-
cidence of resorption of autogenous cartilage, homograft
cartilage, Mersilene mesh, and Gore-Tex was 3.3%, 33%,
0%, and 0%, respectively.69 The revision surgery rate for
autogenous cartilage, homograft cartilage, Mersilene mesh,
and Gore-Tex was 4.9%, 44.4%, 50%, and 6.7%, respec-
tively.69 This study illustrates why autogenous cartilage is
considered the best material for implantation. If insufficient,
a choice between the other possible options must be made,
each with its potential limitations and complications. The
most common problems are extrusion, infection, and resorp-
tion. Less commonly are foreign body reaction, warping,
skin changes and cyst formation (Table 4).
Revision rhinoplasty is a common indication for the
insertion of implants. The fibrosis and decreased vascularity
in revision cases may lead to resorption of autografts and
homografts and doom tissue tolerance of alloplasts. Braca-
glia and coworkers followed 300 cases of revision rhino-
plasties over the course of 1 year (147 cartilage grafts, 89
bone grafts, 10 dermal or temporal facia, and 42 Gore-
Tex).70 In 9 patients costal cartilage grafts were removed
because of warping.70 Partial resorption of the mineral com-
ponent of the bone grafts were seen by x-ray, but external
correction was maintained.70 In the 47 patients receiving
Gore-Tex for minor defects of the nasal dorsum, there was
an infection rate of 10%, and 1 cutaneous fistula devel-
oped.70
Infection can occur early or late postoperatively. The use
of topical antibiotic ointment in the packing material has
been documented to reduce the level of bacterial contami-
nation locally.71 However, atraumatic preparation, and sur-
rounding the implant material with healthy, tensionless tis-
sue are all important factors in preventing infection.
Soaking mesh implants in an antibiotic solution before im-
plantation is a debatable subject, but commonly performed.
The role of perioperative systemic antibiotics in reducing
infection is also controversial.71 However, the majority of
surgeons use systemic antibiotics for patients undergoing
rhinoplasty, particularly when nasal packing or an alloplast
is placed.71 In general, autologous materials have a lower
infection risk than both homologous and alloplast materials.
Tissue ingrowth into mesh implants reduces long-term in-
fections. With infection of homografts and alloplasts anti-
biotic treatment is instituted; however, most implants re-
quire removal. With trauma, the chance of salvaging an
alloplastic graft is very low and most workers favor graft
removal immediately.71 Finally, though considerable debate
is devoted to this topic, there is no evidence to suggest an
increased risk of alloplast infection if placed through a
closed versus open approach.
The potential for resorption exists with every grafting
material, which is usually greater with homografts. Trau-
matization of cartilage, which is mildly antigenic, will result
in significant absorption. In a study comparing crushed and
uncrushed cartilage, significant absorption of crushed carti-
lage appeared by 6 weeks.72 Certain alloplast materials such
as Supramid, Lactosorb, and Surgicel are also associated

Table 4 Comparative incidence of complications with grafts and implants

Resorption Warping Infection Extrusion Skin changes Support

Cartilages ⫹ ⫹ Low ⫺ ⫺ Good
Bone ⫹⫹ ⫹ Low ⫺ ⫺ Rigid
Homograft ⫹⫹⫹ ⫹ ⫹⫹⫹ ⫺ ⫺ Good
Alloderm ⫹⫹⫹⫹ NA Low Low ⫺ None
Silicone ⫺ ⫺ ⫹ ⫹⫹⫹ ⫹ Rigid
Medpor ⫺ ⫺ Low ⫺ ⫺ Rigid
Gore-Tex ⫺ ⫺ ⫹⫹ Low ⫹ Mesh
Mersilene ⫺ ⫺ ⫹⫹ ⫺ ⫺ Mesh
Prolene ⫺ ⫺ Low ⫺ ⫺ Mesh
 Author's personal copy
322 Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
with complete resorption. Some degree of fibrous tissue
replacement occurs but is unpredictable in extent.
The use of fixation with autogenous rib cartilage has
reduced the rate of warping. Certain injectables and allo-
plast materials associated with foreign body reactions con-
tinue to be used in certain parts of the world. Lee and
coworkers described the removal of liquid paraffin and
silicone from Korean patients.73
The site of implant placement is also a factor in outcome.
The dorsum is stable and serves as a better recipient site
than the mobile tip, where movement invites extrusion. Skin
thickness influences implant visibility. With time, thin skin
can “shrink-wrap” around a graft producing visibility, warp-
ing and resorption, especially in the nasal tip. Operative
technique is also important in minimizing graft extrusion,
displacement, and visibility. The dissection of the pocket for
the graft, or implant, must be precise. Edges should be
tapered, creating smooth round corners. With laminated
grafts for dorsal augmentation, the segments must be su-
tured together for stabilization. Placement should be as deep
as possible and not in the subcutaneous tissues.74 Finally,
the presence of systemic disease and immune status of the
patient must be considered in risk assessment and patient
selection.
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