Nasal Augmentation Materials

Implantech Nasal Implants

Dorsal, Columella and Premaxilla Synthetic Implants (nasal augmentation): In reconstruction procedures, as well as cosmetic, nasal implants are utilized to correct deficiencies in the dorsal area (bridge) of the nose as well as the premaxilla (base). Sometimes implants are used to correct cartilage deficiencies or to reconstruct after trauma. It is possible to use bone grafts from your hip, leg  or rib and even cartilage grafts from your septum, ear or ribs. It must be said that "natural" grafts can sometimes deteriorate or be absorbed by the body although I have seen some truly wonderful results with septal, ear and rib cartilage grafts which lasted the life of the patient. Sometimes synthetic implants are used for some patients but have a downside of being palpable (more easily felt and seen) if not placed correctly, as well as infection. 

 

Below we will discuss your options in nasal augmentation, both from synthetic and biological sources...

Such as Implantech makes a wide variety of implants as shown above, as well as carvable silicone blocks. Implantech has over 140 shapes and sizes and add new designs often.  They are my favorite implant company and can recommend them with good conscience.

There are also nasal implants made from expanded, tubular polytetrafluoro-ethylene (ePTFE) implants from Softform or Gore-Tex and even ePTFE blocks to customize an implant for the patient.  

Let's Review Your Options

  • Silicone Implants: Solid silicone has been used as a material for facial implants since about 1956.  The silicone facial implants are solid, yet flexible and very durable.  They are manufactured in different durometers (degrees of hardness) to be soft or quite hard.  These implants are designed to enhance soft tissue areas and not the underlying bone structure.   They are usually easily removed as they are quickly encapsulated by scar tissue. 

    • Popular Manufacturers Of Silicone Implants:

      • Implantech: Implantech has over 140 sizes and shapes of facial implants in stock at all times.  They produce a few new models often and offer a custom 3D scan by using the patient's MRI scan.  The result is a fully customized fit. ImplantTech Associates 

      • Inamed Aesthetics (formerly McGhan Medical): These implants are made from a standard implant grade silicone elastomer and are available in soft, medium, and firm durometers. Inamed Spectrum Facial Implants

      • Advanced Bio-Technologies, Inc.: This company has limited types but does offer carvable blocks (unsterile) like the other companies which can be sterilized in autoclave systems.  Silicone carving blocks and pre-made implants are made of implant grade silicone elastomer and are available in soft, medium, and firm durometers. Advanced Bio-Technologies, Inc.

      • Allied Biomedical: These implants are made of a carvable, solid silicone elastomer designed for permanent implantation.  Facial implants are provided sterile in a sealed packaged until ready for use or for customization. Implants may be trimmed with a scalpel or scissors to meet the individual patient's needs. Allied Biomedical

  • Expanded Polytetrafluoroethylene (ePTFE): These implants are porous and utilize the benefits of tissue integration as well to keep it in place.  Not as firm as the more harder silicone implants.  There is less bone resorption underneath (ePTFE) implants as opposed to silicone implants.  When used for cosmetic purposes this implant rarely exhibits a biochemical reaction.  However, when used in functional surgeries such as TMJ disorder or hip replacement, fragments can rub off of the implant and cause inflammation within the joints.

    • Popular Manufacturers (ePTFE) Implants:

      • Gore-Tex® (Gore Industries Worldwide): This material is made from expanded polytetrafluoroethylene (ePTFE).  It is known as Gore S.A.M. (Gore subcutaneous augmentation material) and is made of biocompatible, micro-porous ePTFE which supports rapid tissue incorporation.  It is flexible, soft and yet very strong, S.A.M. is available in pre-formed configurations (facial implants and the like) as well as sheets and blocks.  The pre-formed Trimensional 3-D shapes improve the outcome of malar, chin and nasal reconstructions or cosmetic augmentations.  An added bonus is that it can also be easily carved for further customization. Gore Medical Products

      • SoftForm®: The SoftForm® implant is also made of ePTFE (expanded polytetrafluoroethylene) and can also be carved.  This implant is flexible, soft yet very strong and rarely causes inflammation when used for cosmetic purposes such as chin augmentation.

  • Polyethylene Implants: These implants are bio-compatible and place no extra stress on the body or effect it whatsoever.  Not saying that Silicone does, it's just another option for your nasal augmentation.  They are porous and rely on tissue integration instead of titanium screws, for stability. These are more difficult to remove. 

    • Popular Manufacturers Polyethylene Implants:

      • MEDPOR® Biomaterial (Porex): MEDPOR® is made of a lightweight, porous form of high-density polyethylene. This material has a long history of medical applications without any reported harmful effects. This implant's porous texture allows tissue to incorporate into the implant, to prohibit "shifting". The shape and size can be customized by your surgeon to fit your individual needs. MEDPOR® is also widely used for facial repair following trauma and for corrections of congenital defects. Although its porous feature can be its downfall, for a porous implant, after tissue incorporation, is more difficult to remove without destruction of tissues. Porex Surgical Products Group

  • Hydroxyapatite Implants: Medical Science has come up with a way to alter coral into an even closure match to bone and that is called Hydroxyapatite or simply, HA.  It has both the porous structure and chemical make-up of bone so that the body accepts it wholeheartedly and even incorporates normal tissue integration and not capsulization like synthetic implants.  A patented process converts Calcium Carbonate into hydroxyapatite while maintaining the three-dimensional integrity of the coral yielding Coralline Hydroxyapatite (CH). All the proteins are removed by intense heat. This renders the structure totally non-immunogenic so it becomes a nearly perfect bone lattice. Closest to bone grafts but without the bone. 

    So how exactly is HA made? "The synthetic material is prepared by heating the coral-which is essentially calcium carbonate with ammonium phosphate at more than 200 °C for 24 to 60 hours to obtain about 95% Hydroxyapatite. The material is processed into block or granular form and sterilized by gamma radiation." (American Chemical Society)

    How long does it last you ask? "The natural porosity of the material does have the drawback of reducing its strength, notes David C. Mercer, Interpore's president and chief executive officer. But the porous structure provides room for bone tissue to immediately grow into the pores of the implant. However, the material is only partially resorbed and replaced by natural bone. The company is now evaluating in pre-clinical studies a related new product that has a higher resorption rate." (American Chemical Society) 

    *Also available in an injectable or spreadable, non-porous paste. See below.

  • Injectable Tissue Augmentation Products: These products offer ease of placement with less downtime although the permanent micro-implants are not easily removed.  Some products are temporary and could be used to "try on" what nasal augmentation would look like although asymmetry is possible as the injectable solution is, of course, not pre-formed and subject to migration within the first few minutes to days. Not all products can be sued for augmentation but some may be used for a buffering material to cover bumpy raphs or fill in dents.

    • Popular Injectable Products:

      • Collagen (technically: suspended bovine collagen):  The most commonly used injectable bovine collagen product in the Unites States is Zyderm and Zyplast.  This product is an injectable bovine-derivative (made from cow collagen) and you will need to have a skin test prior to any treatments.  To determine if you are eligible for collagen treatments your doctor will inject a small amount of collagen usually into your forearm just below the skin's surface.  You should watch the injection site closely for at least 4 weeks for signs of inflammation (red, swelling, itchiness, etc.)  The majority of test reactions occur within the first 3 days, but it CAN happen anytime within this time frame.  About 1 in every 100 tested patients have a negative reaction and cannot be treated with injectable collagen. 

        Collagen injections do cause discomfort without a prior injection of regional anesthesia.  Although there is lidocaine inside of the syringe the initial injections do cause slight to moderate pain.  Especially that not only are they injecting the local anesthetic, they are injecting the thick collagen.  After a bit of collagen is injected into your lip the doctor/nurse has about a 3-7 second window to "massage" your lip and smooth out the collagen within before it firms up.  Half of the injection consists of the saline carrier so you will look very swollen for about 1 to 3 hours until your body absorbs the saline. You may have a few minor bruises at the injection sites.

        • Allergy Test: Required

        • Longevity: 1to 5 months. This is a temporary solution and is not recommended for long term chin augmentation.

        • Approximate Costs: $325.00 for 1.0 cc, $425.00 for 1.5 cc, and $525.00 for 2.0 cc

        • Special Note: Is injected into the dermis, not the muscle.  Injectable bovine collagen is a cream color and patients report a blanching effect which can be visible under the skin. It is not recommended for nasal augmentation.

      • Hyaluronic Acid: There are now many manufacturers of hyaluronic acid products (namely Q-Med Laboratories of Sweden which makes Restylane & Perlane).  Q-Med's products' chemical make up is based on a non-animal hyaluronic acid.  Hyaluronic acid gels are injected into the dermis or lips.  No pre-test in necessary is needed as one of it's main components, Hyaluronic acid, occurs naturally in the body.  Hyaluronic acid is a substance found in all living organisms.  If injected within wrinkles, it lessens the appearance of such.  Once injected it works together with your body's own hyaluronic acid and lasts longer than bovine-derived collagen.  The entire Q-Med hyaluronic line is based on the same type gel from highly concentrated (20mg/ml) stabilized hyaluronic acid - the different "grades", or versions, just vary in particulate size.  There are other companies which have begun marketed non-animal and animal-based products so be sure to inquire if you choose to use these products.

        • Allergy Test: reportedly not necessary, although some offices suggest it just to be safe.

        • Longevity: Hyaluronic Acid Gel is not permanent, it eventually absorbs into the body. Hyaluronic Acid Gel typically lasts 3-6 months in most patients. Hyaluronic Acid is a temporary solution and is not recommended for long term chin augmentation.

        • Approximate Cost: 1cc  $250 to $500. Prices are approximate.

        • Special Note:  Some allergic reactions have been reported by a few visitors to our website, but are still considered very rare.  It can be used more as a buffering agent as opposed to the look of how a build up would be post-revision.

      • Injectable Hydroxyapatite Paste:  There are also injectable paste forms of HA.  Some surgeons have suggested separating the periosteum [: the membrane of connective tissue that closely invests all bones except at the articular surfaces] from the facial bones as proper incorporation and osteoinduction (integration of bone) is not compromised.  However, HA paste is not porous and usually osteoinduction is not possible. Resorption is very possible.  It is not to be used over cartilage.

      • Poly-methyl (methacrylate) (PMMA): This product is best described as Microscopic polymethyl-methacrylate beads suspended in a vector such as bovine collagen, hyaluronic acid and the like.  PMMA was discovered in Germany in the early 1900's.  PMMA in conjunction with medical implantation usage dates back to 1936.  Common usage for PMMA include bone cement (like Palacos), dentures, artificial eye lenses, pacemakers (like Lucite, Palavit and other brands). The PMMA is formulated into microspheres (extremely small round bits) and blended with 0.3% lidocaine for comfort and collagen (3.5%) (or hyaluronic acid) as well.  

        It is injected deep within your skin (the Dermal level) through a tunneling technique with a hypodermic needle. Your injector inserts the needle and pushes the plunger to deposit the the PMMA at the same time pulling the needle out. Thereby leaving a little cylindrical deposit of PMMA left in place of the injection tunnel. There are only a few individuals (0.1%) that may have a reaction to PMMA; PMMA reportedly, is an inert substance and reported as well-tolerated by the body. Of course if the products vector (delivery agent) is bovine collagen, it will degrade within 2-5 months and the microspheres of PMMA are encapsulated (surrounded) by your body's own collagen in about 2-4 months. Thus networking added tissue augmentation without migration of the microspheres. 

        • Popular PMMA Manufacturers

          • Artecoll® Artecoll® is marketed in Canada by CANDERM, INC. and in Mexico by Grupo Venta International of Guadalajara (1-800-368-4600). In the US it will be distributed by Artes Medical, Inc. in San Diego, California. The inventor can be reached at Artes Medical. The first use for tissue augmentation was in 1989 and it is reported that in the last 10 years, more than 100,000 men and women have been successfully treated with Artecoll. This product can be used successfully for injectable augmentation however, any considerable augmentation problems would best be corrected with an implant. Please see their Artecoll website at  www.artecoll-usa.com for more information

            • Allergy test: Required, due to the collagen carrier.  The collagen is absorbed and excreted leaving the microspheres to be encapsulated by the body.

            • Longevity: permanent

            • Approximate Cost: $400.-$900 per cc. The cost for Artecoll™ in Alberta,

            • Canada $800.00cdn per syringe 

          • MetaCrill®: "MetaCrill® is an implant composed with microspheres of polymethyl-methacrylate (PMMA) 20 to 80 Mc micra diameter-- suspended in a chemical coloid, biological inert, composed of carboxi-gluconate-hidro-lactic of magnesium.  The proportion microspheres x coloid is 30%. It is stable in normal temperatures and does not need to be kept refrigerated. It is bio-compatible, non-absorbable and provides permanent correction of any depression in any part of organism introduced."  This product can be used successfully for injectable augmentation however, any considerable augmentation problems would best be corrected with an implant. MetaCrill® Bio-Implante

            • Allergy test: reportedly not necessary
              Longevity: permanent
              Approximate Cost: The cost for MetaCrill® in Mexico, is $500. to $1,000. per treatment 

      • Hydrophilic Polyacrylamide Gel: Also known as "acrylic hydrogel",  "Hydrogel" or "HPG". Hydrophilc means "having an attraction to water". This product is usually a combinations of polyacrylamide (5%), a synthetic polymer, suspended within apyrogenous water (95%).  Unlike all of the other injectables, this one stays soft. After it is injected and after the water is absorbed by the body, the HPG remains pliable and plump like your own soft tissue, not hard like bone. The hydrophilic polyacrylamide retains fluid - so your own fluids keep it plump.

        • Popular Hydrophilic Polyacrylamide Products:

          • Interfal Gel: Interfal was the original Ukrainian product and had many problems with inflammation. It is no longer available.

          • Formacryl: This is a Russian first generation product made by (Bioform) that you made have heard about.  This product is no longer being manufactured and has been replaced by the next product, Argiform.

          • Argiform: This is the second generation product by Bioform of Russia with less residual unpolymerized acrylamide and also has an added antibacterial property. This is considered by many surgeons and scientists to be the safer of the PAAG products.

          • Bioformacryl: This is an Italian-made exact copy of Formacryl.

          • DermaLive: This is a French Product which is also similar to Formacryl.

          • Aquamid: This is also another polyacrylamide product.

      • Injectable Silicone (polydimethylsiloxane oil): Liquid silicone injections are NOT FDA approved for cosmetic applications. In fact, they are illegal (except for clinicals with SilSkin) in the US.  They are approved in the US for retinal tamponades after hemorrhage.  However there is an amendment which allows any approved medical device to be used by any physician on any patient as he or she sees fit.  Injectable silicone is reported as being very unpredictable and having quite a few inflammatory responses.  

        "Silicone oil has many advocates among those who used it prior to Food and Drug Administration (FDA) withdrawal of approval. However, silicone, although chemically well tolerated, becomes encapsulated as a foreign body by a chronic inflammatory reaction. Giant cells surround the material and cannot process any ingested material, establishing a low-grade inflammatory nidus. Fibrous tissue surrounds and encapsulates the silicone; this capsule is avascular and is a potential site of infection. A number of late infections, granulomas, and palpable masses have been reported following silicone use. It has been observed, following injections that silicone droplets migrate into the tissues under the injection site, drawn there simply by gravity. Silicone oil is a frequent cause of granuloma and even of delayed allergic response. Silicone is not biodegradable and is often detected in the human liver." credit: www.facialwasting.org 

        • Popular Injectable Silicone Products:

          • Adatosil: This product is NOT approved for cosmetic use and is only FDA approved as a retinal tamponade in ophthalmic use.  This product has been used off-label for wrinkles, soft tissue augmentation and more and has resulted in tissue necrosis, infection, fibrosis and more.  We can not recommend it for soft tissue augmentation.

          • Silikon 1000: This product is NOT approved for cosmetic use and is only FDA approved as a retinal tamponade in ophthalmic use.  This product has been used off-label for wrinkles, soft tissue augmentation and more and has resulted in tissue necrosis, infection, fibrosis and more when not injected by a highly trained professional.  We can not recommend it for soft tissue augmentation.

          • SilSkin: This product is also an injectable form of liquid silicone oil.  It is considered "medical grade" or "pure silicone" and may still cause granulomas, migrate into surrounding tissues and cause tissue necrosis. SilSkin is entering clinical trials for cosmetic applications.  Although we can not recommend any injectable silicone oil for cosmetic use, SilSkin believes that the completed clinicals will eventually show their product has the upperhand in the market of over any other silicone products. 

  • Bioplastique®: (technically: copolymer formed by polydimethylsiloxane/ methylpolysiloxane vulcanized, texturized, fully polymerized, suspended in polyvinylpyrrolidone) Whew!!! Which, in a hand-basket,  is a polymer micro-implant 100 and 600 micrometer in size. Bioplastique® is a biphasic (meaning  having two phases) copolymer (a product consisting of two substances that combine to make a larger molecule) This copolymer consists of a solid, permanent phase/substance and a carrier gel phase/substance which is absorbed and excreted by the body. Very small, texturized particles of a biocompatible inert polymer, were fabricated and mixed with a hydro-gel solution. The hydro-gel has the consistency similar to honey with exceptional lubricating characteristics. The polymer is freely transported through tissue fluids and excreted, with no changes, by the kidneys. This hydro-gel has been used as a carrier fluid for a variety of medications that have been absorbed and excreted without incident. 

    Many of us are quite concerned with migration of micro-implants such as Bioplastique®.  Here is an explanation to help you understand what size a substance must be in order to not migrate. Most Free Silicone particles, although not proven to cause harm and disorders within the body, are small enough to migrate freely within cell walls and infra-structures. Bioplastique®, however, can not. In order for a substance to remain stationary and be encapsulated by our body's own collagen, its size must be large enough not to be absorbed by the body's cells and vessels and must not be small enough for ease of transportation to the body's lymph nodes. This could prove dangerous as small enough particles could cause cell die off. Bioplastique® particles are both large enough and textured permitting ease of collagen encapsulation (in under 4 weeks).  

From Emedicine.com:

"Bioplastique (Uroplasty BV, Netherlands) is a biphasic material. It consists of solid silicone particles (ranging in size from 100-400 mm) suspended in a polyvinylpyrrolidone (CHNO) carrier.

Once injected, the material elicits a low-grade inflammatory reaction. The carrier is removed by the body and excreted by the kidneys. Collagen encapsulates and localizes the silicone, and animal studies have shown no evidence of foreign body migration. Deposition of collagen progresses, replacing the organic component of the material in a ratio slightly higher than 1:1. Therefore, overcorrection is not advised.

Case series have reported no major complications with Bioplastique other than overcorrection. Subcutaneous placement is recommended to avoid palpable nodularity. Bioplastique is not yet approved by the FDA." (Emedicine.com - Soft Tissue Implants)

This material is not approved for wrinkle or lip augmentation and is still experimental in areas other than the tissue surrounding urethra walls. This is because it is normally utilized in urinary incontinence. However it has been successfully used in dermis augmentation as well as secondary rhinoplasty applications.  It takes up to a week for the hydro-gel to be absorbed and excreted thereafter and is still moldable during that period. Bioplastique® is not "soft" and it is not rock hard, but more like cartilage once encapsulated by your body's own collagen. It is reversible although not easily. The particles must be removed with a micro needle, as in micro-liposuction. It is possible that the area to be corrected (or augmented) may lose it indigenous tissue as well when suctioned out, resulting in an even smaller lip or deeper pitted section of dermis.
Allergy test: Advisable
Longevity: Permanent, yet reversible.
Cost: Unknown
*Note: Bioplastique is not approved by the FDA for use in the US for nasal augmentation. 

Autologous Options: Using Your Body's Resources:

  • Bone Grafts: This can be a serious surgery depending upon the donor site, and there is a degree of it absorption. There is a longer recovery time with bone grafts and an increased risk of bone infection as well as excessive calcifications. Although rib grafts are sometimes reported to "curl", there are conflicted reports from different surgeons on this occurrence. Below is an explanation of how bone grafts are incorporated: 

"1) Induction:  Activation of host osteoblasts and differentiation of primitive mesenchymal cells into chondroblasts and osteoblasts.

2) Inflammation:  Graft invaded by PMN’s and its cellular elements are degraded.  Neurovascularization and mesenchymal proliferatrion follow.  Small avascular autografts can become vascularized within 4-5 days.

3) Soft tissue callous formation:  The cellular matrix of the invading granulation tissue becomes more dense and the vascularity increases.  Osteoclasts continue to remove dead bone, while chondroblasts deposit a new matrix of chondroid on the old bone; this begins to calcify.  In cortical bone there is a preferential removal of necrotic Haversian systems rather than lamellae leading to an increased porosity of the graft.

4) Hard callus formation:  Osteoclasts continue to remove dead bone and also begin degrading calcified cartilage, while osteoblasts lay down membranous bone to replace it.

5) Remodeling:  Graft is remodelled into lamellar bone and a medullary canal is established."

above credit: Yale Medical University Core Curriculum

  • Cadaver Bone Grafts: The above without the additional surgery site. It's from a dead person. Not exactly "autologous" (not actually YOUR tissue) but hey, you can borrow a little from someone who doesn't need it anymore.

  • Septal Cartilage: Sometimes when an individual needs cartilaginous augmentation and doesn't opt for synthetics he or she may be a candidate for augmentation via septal cartilage. Septal cartilage is , of course, from your septum and if you have a good supply it can be used sparingly.

  • Ear Cartilage (rim and concha): If a patient does not have adequate septal cartilage or would risk collapse due to septal cartilage removal there is always the ear cartilage which can be used, Usually a tiny sliver is excised from the posterior (back) of the ear, just behind the rim. This results in an inconspicuous scar and usually adequate cartilage for minor to medium rebuilding. Sometimes both ears are used for more extensive rebuilding. This is actually pretty common in patients who have had too much cartilage removed or have experienced collapse after a primary rhinoplasty or several rhinoplasties by less experienced surgeons.

  • Rib Cartilage: Of course if none of the above are options or if in fact you need more cartilage supply for an extensive rebuilding procedure or simply because of surgeon-preference. Rib cartilage and sometimes even a bone graft from your rib is used. It is usually removed from one of your lower "floater" ribs and although I have had reports of both resorption and "curling" if not placed correctly or simply unfavorable circumstances - it is still a viable option.

In Conclusion
Nasal deformity may result from repeat surgeries, disease, cartilage deteriorating traumas, congenital disorders and even  from prolonged drug (inhalant) use. These deformities may inhibit a person's social life and self esteem. With today's medical technology, these deformities can be corrected and in turn, can restructure an individual's social life and confidence. There is simply no reason for an individual to suffer from low self esteem due to aesthetic objections.


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(Updated on 03/05/10)
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