A graft is defined as any tissue or material that can be from one portion of the body which is placed in another, and is used to improve the results from rhinoplasty surgery. Dr. De Silva uses nasal grafts to improve the aesthetic appearance of the nose by increasing definition, improving symmetry or lifting the nose, in addition to improving functional breathing. Types of grafts include:
A nasal implant is either a synthetic biocompatible or a biological material processed through regulatory approved methods to be used as implants. Examples of synthetic implants are medpor, silicone, or Gor-tex. Examples of biologically derived implants are irradiated rib cartilage from a rib bank or Alloderm (collagen like soft material used to thicken nasal skin). Biological implants may absorb (shrink) to some extent with time but synthetic implants do not shrink or change with time. Synthetic implants are used and have been tested not just for cosmetic or reconstructive purposes in the nose but are used for reconstructive purposes in other parts of the face and body with a long record of follow up.
Natural grafts refers to material taken from ones own body which includes your septum (hidden cartilage that lies between the right and left sides of your nose, ear cartilage and rib cartilage. Benefits of using natural grafts are that they are taken from your own body. Natural grafts are not always available in revision rhinoplasty as previous surgery has removed the grafts, in ethnic rhinoplasty (some ethnicities have relatively small septal cartilages) and specific indications the shape or size of the grafts may be inadequate to achieve the best result. Natural “grafts” sometimes absorb or deteriorate with time, whereas, synthetic implants do not deteriorate. Rib, septum, and ear cartilage have varying degrees of absorption with time. Natural “grafts” sometimes warp (twist) over time and rib cartilage has the higher risk of warping with time. Dr. De Silva does not use patients own rib cartilage due to unwanted risks and potential for injury from damage to the lung or chest wall during surgery, the potential risk that this type of graft may dissolve and bend long-term and the long surgical time required.
Dr. Julian De Silva uses both natural grafts and synthetic implants and sometimes uses a combination of both to achieve the best outcome with maximal support and definition.
Dr. Julian De Silva recommend that healthy non-diabetic patients who are non-smokers are the best candidates for nasal implant use because they are the least likely to encounter an infection and achieve an excellent outcome. Patients with thicker skin also tend to be better suited for certain implants as the thicker skin provides better coverage and protection of the implant. Patients with thin skin may require additional techniques that include a thickening graft of Alloderm or temporalis fascia between the synthetic implant and the patient’s skin. Patients that need implants the most such as Afro-Caribbean and Asians tend to have thick skin.
Dr. Julian De Silva believes that patient selection is very important in planning complex rhinoplasty surgery with synthetic implants to obtain successful long-term results and minimise the risk of infection, movement or extrusion. Dr. De Silva does not recommend using implants in smokers, patients who use illicit drugs in the nose such as cocaine, diabetic patients, or patients with a reduced immunity status. Smokers tend to have a higher risk of infections of the implants and subsequent need for removal.
Nasal implants are used to correct nasal deficiencies in the dorsal area (bridge of nose) as well as many other areas of the nose including the tip or the sides. They may be used to provide additional height or definition to a flat nose or nasal tip in an ethnic Middle Eastern, African, Afro-Caribbean or Asian rhinoplasty. In additionthey may be used to correct a collapse on one side of the nose to make it look straighter. An implant may also be used to support a drooping nasal tip. Implants are frequently used in revision rhinoplasty where too much cartilage was removed from a previous rhinoplasty.
Nasal implants come in varying sizes and shapes for the tip and dorsum (bridge of the nose). However, Dr. Julian De Silva believes it is important to sculpt and customize the implant to the patient and uses prevision instrument shape and sculpt the nasal implant. Using technology sculpting the implants is precise and eliminates sharp edges.
Dr. Julian De Silva, often utilses a patient’s own cartilage (termed autogenous grafts) in rhinoplasty either from the septum or ear or from other sources. However, commonly in ethnic rhinoplasty, the patient’s own cartilage is too small and weak to provide the needed support or definition to the bridge and tip of the nose. Sometimes Dr. De Silva uses autogenous cartilage grafts in combination with artificial implants to give the needed support and definition. Also sometimes in severe saddle nose deformities in revision rhinoplasty or in traumatic noses, one’s own cartilage is not thick enough to give the needed height in a nose. In Asian and black rhinoplasty, the patient’s septum and ear cartilage tends to be thin and weak and inadequate for the support and definition needed in these noses to support their thicker skin. One’s own cartilage can also absorb (shrink) with time and may warp as well with time, whereas synthetic implants do not absorb or warp.
Dr. De Silva’s first choice of graft tissue is using a patient’s own natural cartilage to make graft tissue, this includes the patient’s own septal cartilage (from the patients’ own nose or patients’ ear cartilage). Dr. De Silva also uses irradiated cartilage (harvested from a cadaver in the USA) in some cases, especially in revision rhinoplasty procedures in which the nasal framework needs to be reconstructed. Irradiated cartilage becomes necessary when ear cartilage won’t suffice (because stronger cartilage is needed) and the patient has no extra septal cartilage to harvest. It is particularly useful for reshaping the nasal bridge (repair of previous rhinoplasty resulting in “Ski slope” or scooped nasal bridge) and supporting the nasal tip.
Dr. De Silva prefers to use custom-sculpted Medpor implant in thick skin ethnic noses. The Medpor integrates better than silicone and Dr. De Silva customizes the implant during the procedure with his microburrs and dermabrading system to fit into your nose creating smooth rather than visible sharp or pointy edges. This customized implant integrates by tissue ingrowth into the implant and therefore stabilizing it. The need for an implant In ethnic noses arises when there is poor quality cartilage in the septum and ear characteristic of ethnic patients’ cartilage – though there are some cases where Dr. De Silva has used patient’s own cartilage successfully.