Often I am asked what is the best approach to reconstructing a nose following previous rhinoplasty that did not turn out to the patient’s liking. The main debate will be in regards to the benefits of using foreign material such as silicone implants or Medpor mesh versus cadaver cartilage versus the patient’s own cartilage. I have vast experience with all of the above-mentioned techniques, and I think they all have their place. There is no doubt that the preferable material to use to rebuild the nose would be the patient’s own cartilage in most situations. If the patient’s septum is intact and has a good amount of strong cartilage, this usually is the best approach to rebuild the nose when appropriate.
This cartilage is perfectly shaped, has the perfect strength, and there is no pain or extra healing involved to take this cartilage out of the septum at the same time as the rhinoplasty. Furthermore, the patient will usually breathe better following removal of the septal cartilage. However, there are times where this is not an option for one of many reasons. Oftentimes, following a rhinoplasty, the rhinoplastic surgeon will use the septal cartilage or damage it in some way. In either case, there may not be adequate septal cartilage to use to reconstruct the nose; in which case, there are several options.
In my opinion, the safest synthetic material to use to rebuild the tip and support of the nose would be Medpor Mesh and I have used this in over 100 patients who did not have appropriate septal cartilage and did not want me to take cartilage from either their ear or their rib which we will discuss shortly. In this case, Medpor can be opened up as it is prepackaged and shaped and placed into the nose. This is a mesh material which has ingrowth of blood vessels and tissue which makes infection unlikely and makes stability quite predictable. In over 100 patients, I have had to remove the Medpor on only one person because of infection.
The alternative to Medpor would be to use cartilage. Cartilage can either come from the patient or from cadaver. When cadaver cartilage is used, the cartilage is harvested from the cadaver and then radiated to make sure there is no chance of any kind of transmittable disease. The cartilage is then shaped as it would be if the patient’s own cartilage was used and placed into the appropriate position. The benefit of this is that it saves time and saves the extra healing that is involved with taking cartilage from the patient’s ear or the patient’s rib. The downside of using cadaver cartilage is that it theoretically would not last permanently and would theoretically resorb or disappear over time which does not happen with the patient’s own cartilage. This is a controversial topic and many surgeons who use the cadaver cartilage insist that it has very predictable longevity, but opponents of this technique do claim that it does disappear over time and therefore is less beneficial than using the patient’s own cartilage. The next option is using the patient’s own cartilage.
When the septum is not available, the patient’s own cartilage will either come from the ear or the rib. Ear cartilage is easier to harvest; however, ear cartilage is not ideal for most parts of the nose because it is so curved and difficulty to work with. Therefore, when a significant reconstruction has to be done, I will almost always use rib cartilage versus ear cartilage. When using rib cartilage we make an incision near the patient’s fold of the breast to hide the scar and then remove a section of the sixth rib. The patients will never miss this cartilage and will have no defects or deficiencies from this removal of cartilage. They will be slightly sore for several weeks potentially, but the healing is actually pretty mild with rib cartilage. However, rib cartilage does provide a big block of cartilage that can be shaped into any configuration needed and therefore a complete reconstruction can be done with rib cartilage. This cartilage is straight and strong and is the ideal cartilage when septum is not available. The downside of rib cartilage is that there is a scar in the breast fold and it does take anywhere between an hour and two hours extra to harvest, making the surgery that much longer.
The final material that is noteworthy would be silicone implants. Silicone implants are ideal for rebuilding the bridge. The silicone, in my opinion, should never be used in the tip of the nose, but for the bridge it is actually quite ideal because it is perfectly straight and smooth and gives very beautiful results.
All the above-mentioned techniques have their pros and cons and their benefits and risks to each of the above-mentioned techniques. Provided your surgeon has good experience with the method they choose, you should expect to have excellent results regardless of which technique is used.