Augmentation of the nose for adding to height or increasing projection and shape of the tip is a very common request in rhinoplasty. Having a high nasal bridge or a well shaped and projected nasal tip can accentuate the nose and as the central-most feature of the face, nasal shape can help define your facial features and has a strong relationship of how we visualise the proportions of the face. A small nose for example can make a chin appear longer or larger.
When it comes to adding volume to a nose, the gold standard is cartilage. Being a natural, mouldable biologic tissue that has low metabolic activity, meaning that it can easily be grafted or moved from one place to another and remain viable, cartilage is a versatile tissue to work with and is usually the option of choice for most rhinoplasty surgeons. But what are the alternatives?
Hyaluronic acid fillers
Liquid rhinoplasty has become an increasingly popular option in augmentation of the nasal profile. Whether it is to increase nasal height, tip projection or to mask irregularities such as a dorsal hump, dermal fillers can be performed in an office setting with immediate results and can be a very satisfying procedure for both the patient and injector.
The most common criticism for fillers is that they are only temporary. Product information approximates a period of 8 - 12 months. The reality however is that fillers can last much longer. It is not uncommon to find remnants of filler in rhinoplasty operations that were supposedly injected 3-4 years ago and often there are surrounding soft tissue changes around the filler that will never disappear completely. From experience, filler in the upper 1/3rd of the nose where the skin is thin and loose appears to last much longer than filler used for tip definition.
The primary concern for filler that should be noted is in fact the risks associated with injection. All dermal filler injection has risks associated with it and this should be discussed in detail with your treating clinician. The nose in particular however has a much higher risk profile as it is a very vascular area and carries the highest risk of possible blindness associated with filler injection into blood vessels around the nose. This is a very rare but severe complication that can occur and is the most important reason why you should always check that your injecting clinician has the experience and certification to inject as safely as possible.
Silicone is likely one of the most common non-biologic materials used in rhinoplasty worldwide and its use is predominant in Asia. An inert material, medical grade silicone has long been used as an augmentation material as its properties avoid reaction while forming a capsule around the implant that separates it from the surrounding tissues.
Silicone rhinoplasty is a quick and relatively simple way to increase nasal bridge height and tip projection. Its properties of being firm yet elastic allow for an excellent improvement in nasal bridge contour and it can be inserted through a ‘closed’ technique without external scar.
Unfortunately, silicone remains a foreign material and the inherent issues surrounding implantation of any non-biologic device inside the body remain. There is no ability of the material to withstand infection and any minor degree of contamination will lead to implant loss eventually. Implants that have remained ‘stable’ for many years without apparent problems can still develop problems of infection and it is all too often that a patient will present with worsening redness and pain at the nasal tip which will only settle with surgical removal of the implant and washout. Some patients will be aware of this risk, however what is not explained thoroughly is the amount of scarring and internal damage that an infective implant complication can have on the nose’s original anatomy.
Long term results of silicone rhinoplasty are too often complicated by issues of implant displacement and even erosion of the implant through the thin nasal skin. It is for these reasons and the high numbers of patients that come to see me for revision to treat these complications that I never use silicone augmentation in the nose.
Another non-biologic material that is less commonly used is Gore-tex. Gore-tex is a porous polymer material that is manufactured as a sheet. The surgeon will rolls this up into a cylindrical shape and insert along the bridge of the nose as an alternative to silicone.
As a more porous material, Gore-tex allows for some ingrowth of tissue and it is reported that the risk of infection and long term implant loss is lower than silicone.
Criticism of Gore-tex however is that the implant is soft to touch and therefore difficult to achieve fine definition of the nose. As a non-biologic material, the same issues arise in the unfortunate instances of infection however Gore-tex in some ways can be more challenging to remove due to the porous nature of the material.
The gold standard for nasal restructuring - cartilage has always been the material of choice for reconstructing or remodelling the nose as the principles of plastic surgery have always begun with replacing ‘like with like’. The biologic framework of our noses is made from cartilage and bone and it would only make sense that cartilage, when available, surpasses any other material in terms of safety and longevity in augmentation of the nasal framework.
Cartilage can be used in many different ways in the nose. Entire blocks are occasionally used to reconstruct or augment the nasal bridge. Smaller sheets can be used to modify existing cartilage frameworks such as adjusting tip projection or height. Crushed cartilage can be used to cover sharp bumps or angulations and finally diced cartilage is used to augment the nasal dorsum.
Cartilage has been used in these ways to make almost any change to the nose that the rhinoplasty surgeon requires, however the limitation has always been in the availability. While some cartilage can be ‘borrowed’ from inside the nose, taking too much can lead to instability of the nasal framework and for this reason alternative sites for cartilage harvest include the ears and rib cartilage. Mose augmentation rhinoplasties and almost all revision procedures will require accessing cartilage from these alternative sites with the downsides being additional scarring and recovery from the operation extending to areas outside of the nose.
A relatively new alternative to this option is cadaveric donor cartilage. Donor cartilage carries the same properties as a patient’s own cartilage and due to the inert nature of cartilage tissue in general there is very little cellular activity and therefore low immunogenic reactivity in cartilage per se. In addition, the donor cartilage is irradiated to remove any viable donor cells leaving essentially a non-living biologic framework that allows ingrowth of the recipient patient’s own cells into the tissue to allow complete integration without risk for rejection and loss of the cartilage.
The only limitation of cartilage is that it is a biologic material and therefore needs to integrate and have nutritional supply to survive. As a principle, not all grafted material will survive this process and there is always going to be a small degree of volume loss over time. Experience has shown that the degree of volume loss is seldom noticeable and the benefits of using this material in its safety and long term reliability far outweigh this limitation.
Unfortunately, there is no ‘perfect’ option for material used in nasal augmentation. Each of these options have their limitations and even cartilage has a disadvantage of requiring additional donor areas and is a more complex operation. Seeking consultation with an experienced rhinoplasty surgeon with knowledge of these options will help you to make a decision towards which of these is right for you and what is best for you to achieve the results that you require. Your surgeon should be able to inform you of the risks, both short and long term for any of these options and as always it is important that you research your procedure and the experience and credentials of the surgeon prior to making your well informed decision.
Dr Chris Ahn is a Specialist plastic surgeon with a special interest in aesthetic facial surgery and rhinoplasty. He is a current member of the Australasian Society of Plastic Surgeons and the Australian Society of Aesthetic Plastic Surgeons and is a Fellow of the Royal Australasian College of Surgeons - the only peak body accrediting Specialist Plastic Surgeons in Australia and New Zealand.