Nasal Alloplastic Implant Failure

Authors:
Vienna G. Katana, DO
Navy Medicine Operational Training Center, Surface Warfare Medical Institute, San Diego, California

Margaret C. Green, DO; Nadine H. Ruth, MD; and Thomas K. Barlow, DO
Naval Medical Center San Diego, California

Citation:
Katana VG, Green MC, Ruth NH, Barlow TK. Nasal alloplastic implant failure. Consultant. 2018;58(3):119-121.

An 81-year-old Filipina presented to a dermatology clinic with a painless ulcerated lesion on her nose. The lesion had developed 8 months prior, and since then she had noted frequent bleeding.

Her medical history was notable for moderate plaque psoriasis, eczema, hypertension, hypothyroidism, and osteoporosis. She denied having undergone rhinoplasty and denied a history of cancer.

Physical examination showed a 1.5 × 1.3-cm crusted, circular plaque with an ulcerated border located on the left nasal root (Figure 1). Histopathology test results of a punch biopsy specimen showed an ulcer and granulation tissue but no evidence of malignancy.

The lesion persisted throughout the next year; further workup had included 2 additional biopsies, both with nonspecific findings; histologic staining, with negative results for fungi and mycobacteria; and sinus radiographs, with normal findings. Treatment trials with oral antibiotics and topical imiquimod failed to help.

On physical examination almost 2 years after the woman’s initial presentation, a firm white material was visualized at the ulcer base (Figure 2). A consulting otorhinolaryngologist confirmed the object to be an alloplastic implant (Figure 3). Further questioning of the patient elicited a history of cosmetic rhinoplasty 20 years earlier in the Philippines. Explantation led to the prompt resolution of the chronic wound.

Some time later, in an unrelated case, a 53-year-old Filipina presented to the same dermatology clinic with a 2-month history of a nonhealing ulcer on her nose. The woman had a medical history of type 2 diabetes mellitus and hyperlipidemia. Her surgical history was not considered, and she denied a history of cancer.

Physical examination showed a 1.2-cm indurated plaque with central ulceration on the right nasal radix (Figure 4). Biopsy results demonstrated an ulceration and nonspecific inflammation but no malignant features. Fungal cultures of the specimen identified Candida parapsilosis. A trial of oral antibiotics and antifungals resulted in no clinical improvement.

Prompted by the recall of the earlier patient’s case, a surgical history obtained at this patient’s follow-up visit revealed that she had undergone nasal augmentation with an alloplast more than 20 years earlier. After explantation, the residual skin deformation was palliated with intralesional corticosteroids and botulinum toxin type A injection while revision rhinoplasty was explored.

NEXT: Discussion

Discussion. Asian rhinoplasty presents a unique anatomic and aesthetic challenge in plastic surgery. In contrast with Western rhinoplasty, in which reductive procedures prevail, Asian noses often are “westernized” by enhancing the radix, dorsal height, and tip projection.¹ Septal cartilage is the graft of choice for primary nasal reconstruction and augmentation²; however, the septal cartilage typically is thin and small in the Asian nose.¹ In addition to the limited availability of cartilage at the septum, autologous cartilage harvested from other sites is associated with extensive handling and operation time, donor site morbidity, and unpredictable resorption rates.³ Therefore, alloplastic implants often are preferred over autologous grafts in Asian rhinoplasty.¹

Widely used alloplasts are made of silicone, expanded polytetrafluoroethylene (ePTFE, or Gore-Tex), or porous high-density polyethylene (Medpor).³ Silicone implants are the most popular of the 3 and are often first-line choice,² given that they are generally regarded as biologically inert, nonimmunogenic, pliable, and relatively inexpensive.⁴ Nevertheless, silicone implants are associated with skin and soft tissue complications and other long-term adverse outcomes in as many as 36% of cases, including displacement, extrusion, infection, and capsular contracture, all of which can lead to implant failure.³

In addition to the risk of fibrous encapsulation with or without calcification, the skin and soft tissue envelope overlying the capsule and implant is subject to damage from chronic inflammation and contracture.⁵ We suspect this mechanism as the cause of the ulcerated masses observed in both patients described above. Interestingly, the implant of the patient in case 1 was devoid of calcium deposition and was radiolucent on plain radiographs, thus adding to the protracted treatment course before surgical removal. Complex surgical histories and bizarre clinical presentations (eg, nasal dorsal cyst,⁶ forehead cutaneous fistula,⁷ facial edema,⁸ calcinosis cutis of the nasal dorsum,⁹ nasal tip ulceration¹⁰) resulting from complications of alloplasts have been described.

Eliciting a distant surgical history can be challenging given that patients may be reticent for cultural reasons to disclose having undergone augmentation and (like the patient described in case 1 above) may not consider nasal implantation to be rhinoplastic surgery. Surprisingly, there have been other reports of patients who, like both of our patients, were unaware that a nasal implant had been placed during surgery.^7,11

In light of published reports of complications, including our patients’ cases, the long-term durability of silicone is a matter of concern. These implants may be extruded given their nonporous structure that is impervious to the tissue ingrowth that has been shown to stabilize alloplasts made of other materials.² Nasal dorsal masses may be the heralding sign of a chronically inflamed capsule and impending extrusion, as in case 1 above; moreover, the associated damage to surrounding soft tissue creates a residual defect that can impede future revision surgery,¹² as in case 2 above.

Among 581 patients presenting for revisional rhinoplasty in Korea, Kim and colleagues³ found that contracture (35%), displacement (30%), and overlying skin problems (20%) were the most frequent complications associated with silicone implants, whereas tip contour deformity (53%) and infection (24%) were the most frequent complications associated with ePTFE implants. Although the cases in Kim and colleagues’ study spanned a 10-year period and included the explantation of a 20-year-old implant and a 30-year-old implant, both with a fibrous capsule, the authors did not report on the latency period correlated with the complications. The authors of a survey of surgeons and a retrospective literature review of the safety and efficacy of alloplastic materials and allografts reported comparatively lower rates of extrusion (2.1%), infection (3.7%), and displacement (3%) with silicone implants; however, the studies reviewed did not report beyond a 3-year follow-up period.² Nevertheless, the risk of complications and implant failure appears to increase over time, but to what extent is largely unknown.¹²

In conclusion, nasal augmentation with alloplasts is a common procedure in Asian rhinoplasty. Inflammatory nasal lesions may be the first signs of alloplastic implant failure. Late complications may not be attributed to the remote history of surgery, delaying definitive diagnosis and treatment. Familiarity with long-term skin complications associated with alloplastic materials is essential. A detailed history is paramount so as to avoid mistaking delayed skin complications secondary to synthetic implant failure for an atypical infectious process or a cutaneous malignancy. 

References:

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Disclaimer:

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the US Government.