Reconstruction of the Major Saddle Nose Deformity Using Composite Allo-Implants
02 June 2008 (online)
The major saddle nose deformity leaves a patient with an obvious aesthetic deficit as well as an equally disturbing functional handicap. Reconstructing the collapsed dorsum and tip and simultaneously restoring nasal function present a formidable challenge which has elicited a wide variety of solutions ranging from the use of a toothbrush handle to split calvarial grafting.1 As Murakami et al pointed out, the “variability exists to a large extent, because the saddle nose deformity is not a single entity but rather a spectrum of abnormalities.”2 Attempts to categorize saddle nose deformities are useful; however, they often lack the simple impact and clarity of the pre-operative photograph. Moreover, the categorizations have not led to a uniform approach to this complicated problem.
Nevertheless, Tardy's classification of minimal, moderate, and major saddle nose deformities provides a helpful framework for discussion of reconstructive options. Minimal deformities demonstrate a supratip depression of 1 to 2 mm and are easily corrected with cartilage or fascial overlays. Moderate saddle nose deformities are characterized by a significant loss of dorsal height as well as columellar retraction and broadening of the bony pyramid. A major deformity demonstrates “all of the stigmata of the moderately saddled nose, only to a more marked degree.“3 In Tardy's opinion, an open approach may be warranted in these cases.
We offer one solution to the major saddle nose deformity using a composite allo-implant of porous high-density polyethylene (PHDPE) (Medpor surgical implants, Porex Surgical, Inc., College Park, GA) and purified acellular human dermal graft (Alloderm, Life Cell Corp., TX.). While we readily admit that autogenous tissue is the preferred grafting material, we have encountered patients in whom this is not an option. Major saddle nose deformities typically require more augmentation than stacked septal or auricular cartilage can provide. Additionally, in patients seeking revision rhinoplasty, sufficient donor septal or auricular cartilage is often lacking. Resorption of irradiated cadaveric rib grafts has led us away from this material. Split calvarial bone grafts are our next recommendation for these patients; however, many patients refuse this option.4 In these patients we have turned to a composite allo-implant of PHDPE and acellular human dermal graft for reconstruction of the collapsed dorsum and tip.
Patients with a major saddle nose deformity require dorsal augmentation and tip support (Fig. 1). A dorsal implant with a tip component is used to restore height to the saddle nose. An ultrathin sheet (0.85 mm) is cut to form a thin columellar strut. The aesthetic improvement is coupled with a recovery of function made possible by the strong support offered by PHDPE. While patients were generally satisfied with the results, we noted an abrupt demarcation in the soft tissues of the dorsum along the lateral aspect of the PHDPE implant in several individuals (Fig. 2). Attempts to contour the edges of the PHDPE implant did not significantly alter this feature. Favorable experience with the use of purified acellular human dermal graft (Alloderm) for lip augmentation and treatment of nasolabial folds led us to the use of Alloderm in conjunction with PHDPE nasal implants as a means of camouflaging the edge of the implant.
major saddle deformity - composite allo-implants