Nasal Silicone Implants: Please, No More! [Nasal Implant Removal, Revision Rhinoplasty, Contracted Nose Surgery]

01. Aesthetic Problems

i) The tip is too high and pointed  

ii) A straight-line nose because the glabella is too high (when a silicone implant is placed in a nose with a dorsal hump),

iii) The silicone outline becomes visible (in proportion to time)

02. Internal (Physical and Histological) Problems

(A) Physical side effects ▶ Structural changes: a pulling sensation in the nose and glabella, stiffness, headache, thinning of the skin,

extrusion, deviation of the silicone, protrusion of the columella inside the nose as the tip cartilages are compressed,   

(B) Histological side effects: contracture (upturned nose, various tip deformities, a more distinct silicone outline),

skin color change (redness), inflammation

Various Problems of Silicone Implants

Among patients who have had dorsal hump surgery, we often see cases in which silicone was used.

Whatever the reason, this is clearly bound to lead to a poor result.

Silicone is fundamentally an implant used to raise the height of the dorsum,

so there is no reason to use it in dorsal hump surgery, which reshapes a bulging dorsum to make it straight.

Looking at cases in which silicone was used in dorsal hump surgery,

the bulging hump could not be made straight, and silicone was used to cover it.

When a hump is covered with silicone in this way, the dorsum becomes higher,

so the tip has to be raised even more, which places excessive tension on the tip skin; the skin of the tip becomes thin

and firm, and the pulling of the skin causes discomfort.

In addition, the dorsum and tip become too high, giving the nose an unnatural overall shape.

Therefore, surgery for a dorsal hump or a deviated nose must, without exception, be performed using autologous tissue alone.

Dorsal hump surgery with silicone?  No!!

When a silicone implant is placed in a nose with a dorsal hump, the dorsum becomes too high, and to match it

the tip must also be raised high, so the tip ends up excessively high and pointed and looks unnatural.

In addition, when tension in the tip skin increases, the nose and mouth feel tight and stiff, which is uncomfortable.

PH

A 31-year-old man. Several years earlier, during dorsal hump surgery at another clinic, he received silicone on the dorsum

and a septal extension graft and an ear cartilage cap graft at the tip.

CC

Ever since the surgery, the tip had been too high, tight, pointed, and unnatural,

so he wished to return to his original appearance.

P/E

To connect smoothly with the height of the bulging dorsum, the tip already has to be raised considerably,

and with silicone added on top, the tip had to be raised about twice as much.

As a result, not only had a septal extension graft been used, but ear cartilage had also been placed on top of the tip.

Silicone was palpable on the dorsum, and the tip was fixed and firm because of the septal extension graft.

The tip is too pointed.

OP

The silicone, the septal extension graft, and the tip cap graft were all removed,

and combined repositioning of the tip cartilages was performed.

The photo on the left shows the nose after skin dissection: the silicone was displaced to the left,

Ear cartilage had been placed on the tip, apparently to raise the tip height considerably.

A septal extension graft, intended to increase the length and height of the nose, had been added at the tip.

The tip, which had been displaced to the right by the septal extension graft,

settled well in the center after removal and repositioning.

The tip, which had looked exaggerated because it was long, pointed, and high, became natural.

The patient was pleased that the tightness in the tip was gone and the nose felt comfortable.

After the removal surgery, the nose has returned to a comfortable, natural appearance.

A man in his 20s who, as in Case 1, had undergone dorsal hump surgery at another clinic,

with silicone placed on the dorsum and a septal extension graft at the tip.

Because the silicone, together with the hump, made the dorsum higher,

Because the tip has to be raised even higher, the tip becomes pointed and comes under severe tension.

When silicone is placed during dorsal hump surgery in this way, the nose becomes too large and the tip comes under considerable tension,

A poor result is inevitable.

Deviated Noses and Dorsal Humps Must Be Operated on with Autologous Cartilage Alone!

About 70% of dorsal humps are accompanied by a deviated dorsum.

This is because the growth center of the nose lies where the nasal bones meet the middle cartilages,

As excessive growth takes place at the growth plate during adolescence, together with the hump

causes the nose to deviate to one side.

Therefore, the hump develops at the midpoint of the nose, where the nasal bones meet the dorsal cartilage. 

The protruding, deviated framework of the nose therefore has to be reshaped and straightened,

and artificial materials such as silicone, mesh, or Medpor should not be used for this, nor are they needed.

PH

35-year-old woman, no surgical history

PE

(A) The axis of the nose is bent. (The dorsal line running down from the glabella slants toward

       the patient's left and then bends back toward the center at the tip.)

(B) A hump bulging on the dorsum is visible, and the tip also droops slightly.

(C) The columella and the septum, marked with a yellow line, can be seen to be out of alignment with each other.

      In other words, the septum is deviated to the patient's left.

OP

A hump is never corrected simply by rasping the hump itself,

The reason is that if only a single point is rasped down, the dorsal line does not become straight and a bulginghump still

remains. The hump therefore has to be resected over a long span, and measured at its most prominent point,

at least 3 mm must be removed. 

After this resection, a spreader graft, which rebuilds the open roof, must be performed.

The spreader graft not only rebuilds the roof but also straightens the deviated septum. 

The photo on the left was taken after septoplasty:

the septum, which had been bent to the left, has been brought to the midline and straightened.

The photo on the right shows the pieces of septal cartilage obtained through septal resection.

These cartilage pieces are used as spreader grafts placed alongside the septum,

straightening and reinforcing the curved septum. 

The dorsal line, which had been bent and irregular, became straight after surgery.

The tip, which had drooped downward, is now well defined and lifted.

The tip, which had been bulbous, is now slim and well defined. 

The tilted columella now stands straight as well.

Before surgery,  the bridge leaned to the left and the tip bent back in the opposite direction,

After surgery, the bridge runs straight down to the tip.

A typical dorsal hump, with a bulging dorsum and a drooping tip, became a straight, slim nose after surgery.

At the same time, the nose became neither lower nor too large.

When no implant is placed on the dorsum, only the minimum amount of the hump is removed, and the tip is lifted in this way,

the dorsal line becomes smooth and the tip well defined without the nose becoming lower.

Not only was the dorsal line uneven, but the width of the dorsum was also irregular;

after surgery, the dorsal line became straight.

The dorsum is straight and the tip well defined, yet the nose is neither too high nor too small, giving a balanced appearance.

Histological Changes in Silicone Contracture

It is well known that silicone implants cause contracture. 

Contracture is one of the most common side effects that appear after rhinoplasty,

and the nasal deformities it causes are also highly varied.

Today, we will look at the histological changes to see by what mechanism contracture

causes the skin and tissue to shrink and deform, and then review a case of the pinched tip,

one of the more common forms of contracture deformity.

In technical terms, silicone contracture is called "capsular contracture."

In other words, although silicone is the cause of contracture, histological analysis of contracture shows

that a capsule forms and it is this capsule that produces the contracture.

Capsular Contracture: Biological and Histological Analysis

< Capsular Contracture: Various Factors >

Imunological mechanisms play a major role in the development of CC.

Infections are the leading cause of morbidity after breast augmentation,

as proposed by Pittet et al. Here, the degree of CC seems to be associated with a prolonged or

accelerated inflammatory process. 

This inflammatory process might be exaggerated by local factors such as hematoma or infection,

or even by an invasion from remote-to-implant, which further increases the degree of

inflammation, finally leading to fibrosis. 

The development of a septic biofilm at the time of implantation or within the first minutes to

hours, and the subclinical infection of the foreign material, especially with Stapyhlococcus

epidermidis and Propionibacterium acnes, is described by many authors as having a strong

effect on the formation of CC. 

There is also a positive linear correlation between the severity of the contracture and

the local inflammatory reaction.

Injury to the capsule and surrounding tissue causes fibrosis, resulting in CC.

(repeated operation, trauma)

Correction of a Pinched Tip Caused by Silicone Contracture

A silicone implant causes capsule formation and chronic inflammation inside the nose,

and, depending on their severity and duration, carries a high risk of causing contracture (a shrinking deformity).

Nasal deformities caused by contracture

i) an upturned tip

iii) a pinched tip

iv) a twisted tip

among others.

Of these, pinching and twisting of the tip are difficult to correct and require extensive experience and well-practiced technique.  

Today, we look at the correction of pinched and twisted tip deformities.

PH

40-year-old woman; rasping + L-shaped silicone implant 15 years ago. Frequent, persistent bruising on the dorsum. ▶ Gradual pinching.

In rhinoplasty, the tip is commonly raised and narrowed at the same time.

When round, bulbous tip cartilages are gathered toward the center, they become projected and pointed,

and a groove appears on each side; this is called pinching. 

The term means that the tip looks as if it has been pinched with a clothespin. 

When the tip cartilages are gathered toward the center in this way, the nostril margin (alar rim) is pulled upward

and the nostril looks triangular; this is called notching or alar rim retraction.

However, although pinching and notching can appear right after surgery,

they more often develop gradually over time, without the patient noticing. 

When pinching and  notching progress gradually in this way, silicone contracture is the cause.

Silicone contracture thus not only turns the tip upward

but is also often accompanied by pinching and notching as the tip shrinks.

The most powerful way to resolve this is the lateral crural strut graft (LCSG) of the tip.

This graft uses autologous cartilage (septal, ear, or costal cartilage).  

As shown in the illustration, pinching and notching deformities occur when the tip cartilages are crowded toward the center and pulled upward.

Therefore, to make the crowded tip look natural again,

the usual approach is to spread the tip cartilages out to both sides, as in the illustration on the right. 

A: After removal of all the silicone, capsule, scar tissue, and so on. The tip cartilages had been lifted and drawn toward the center by the contracture.

B : The removed silicone and capsule.

C: After lateral crural strut grafting using ear cartilage.

OP

After the contracture was resolved by removing the silicone and capsule, the pinched, crowded tip cartilages were released

Lateral crural strut grafting was performed with ear cartilage. The height of the dorsum was reinforced with acellular dermal matrix.

Results

After surgery, the pinched appearance of the tip was released and became gently rounded (pinching corrected),

The alar rim (the border of the nostril), which had been pulled up into a "^" shape, has come down into a gentle curve.

(The notching has been corrected.)

The pointed tip changed into a rounded, gentle curve,

and the vertical groove-like line along the alar rim was flattened and became smooth.

Because of the contracture, there were (1) a pointed tip, (2) a deeply indented line,

(3) alar rims (the border of the alae) that looked sharply bent, among other findings.

After the silicone and capsule were removed and

a lateral crural strut graft was performed with ear cartilage, all three problems, (1), (2), and (3), were resolved.

The tip, which had been upturned and pinched by contracture, became long and natural with a derotation graft and

a lateral crural strut graft (LCSG).

As the upturned tip came down, the nose gained sufficient length.

PH

18 years earlier: silicone (closed approach) -> contracture

9 years earlier: silicone replaced. Tip plasty with ear cartilage (open approach) -> nostril asymmetry. The columella became deviated.

6 months later: silicone replaced again. Ear cartilage harvested once more (open approach).

CC

The silicone was thick and noticeable. Sensation in the tip skin felt abnormal.

P/E

A typical appearance of contracture: the silicone outline is visible, and the tip is pointed with pinching.

OP

The L-shaped silicone implant, the capsule, the inflamed tissue, and the columellar strut were removed,

The pinched left alar cartilage was flattened out and repositioned (lateral crural reposition), and the columellar cartilages were sutured together.  

Columellar protrusion was visible inside the nose, and the tip leaned to the left because of pinching of the patient's left tip cartilage.

After surgery, the bent lateral crus of the tip was completely straightened, and the tip shape became natural. 

Before surgery, the edge of the silicone on the dorsum was clearly visible,

and the tip showed pinching and notching and was deviated to the left.

After surgery, the dorsum looks natural, the tip deformity is gone, and the tip sits well in the center.

As this case shows, when contracture deforms the tip cartilages and

pinching and notching appear, the axis of the tip often becomes deviated or twisted.

A lateral crural strut graft or lateral crural repositioning is the most powerful solution.  

The pointed tip became soft and natural.

Although it is only 1 week after surgery, there is almost no swelling and the nose looks natural.

Columellar retraction was visible before surgery; after surgery, the columella came forward in a soft curve.