1. Autologous Cartilage (Ear Cartilage or Rib Cartilage)
• What it is: Autologous cartilage refers to cartilage from your own body, typically taken from the ear or rib. It is a biological material that is often used in nasal reconstructive surgery.
• Why it’s used:
• It’s highly biocompatible because it comes from your own body, which means there’s almost no risk of rejection.
• It’s structurally stable and durable, providing long-term support for nasal structures. It is less likely to degrade or lose its shape over time, especially when placed in areas that lack strong blood flow, like the nasal septum.
• It is self-sustaining in terms of volume and structure, so it provides a lasting solution to restore the nasal shape and function in patients with ENS.
• Limitations:
• The harvesting of cartilage requires an additional surgical site (from the ear or rib), which means there is a risk of complications, such as infection or scarring.
• Bending or reshaping of the cartilage can happen over time, but this is generally minimal and slower compared to other materials.
Donor Cartilage (Cadaveric or Irradiated Cartilage)
What it is: Donor cartilage refers to cartilage harvested from cadavers, which is then processed and sometimes irradiated to reduce the risk of immune rejection. It is often used in nasal reconstruction when autologous cartilage is not available or desirable.
Why it’s used:
Donor cartilage provides a structural material similar to autologous cartilage, offering a balance between durability and biocompatibility.
Unlike ear or rib cartilage harvesting, it does not require an additional surgical site, reducing patient morbidity.
In some cases, it can be processed to maintain cellular components that promote better integration with the recipient’s tissue.
Limitations:
The processing and sterilization of donor cartilage may affect its mechanical properties, making it less resilient compared to autologous cartilage.
There is a risk of resorption or gradual breakdown over time, particularly if the cartilage does not integrate well with surrounding tissues.
Although rare, there is a small risk of immune reaction or infection despite rigorous screening and sterilization procedures.
BDCM (Biodegradable Collagen Matrix)
• What it is:
BDCM is a collagen-based material that serves as a biodegradable matrix. Common products include Durepair (Medtronic) or Duramatrix (Stryker). It is often used in tissue reconstruction, where it provides a scaffold for new tissue growth.
• How it works:
• BDCM is designed to be temporary: It encourages the regeneration of tissue and is broken down and absorbed by the body over time. As it biodegrades, it stimulates the growth of new tissue that gradually replaces the implant.
• It is flexible and can be easily shaped to fit the exact needs of the surgery site. For ENS, it would serve as a support to restore volume and shape.
• Limitations:
• Since it breaks down over time, it doesn’t provide permanent support. In areas with low blood flow, like the space between septal mucosa and cartilage, it’s unlikely to be replaced by healthy, functional tissue, leading to loss of volume once it degrades.
• It heavily depends on vascularization and blood supply to integrate with the surrounding tissue. In poorly vascularized areas, the regenerative process might be limited, reducing the effectiveness of the implant.
Acell
• What it is:
Acell is an extracellular matrix (ECM) material derived from animal tissues (usually porcine). It doesn’t contain living cells but is made of collagen and other proteins that promote tissue regeneration. It’s often used in wound healing and soft tissue reconstruction.
• How it works:
• Acell acts as a scaffold that encourages the growth of new tissue and angiogenesis (blood vessel formation). The body’s own cells migrate into the matrix, filling in the space and replacing the material over time.
• In nasal reconstruction for ENS, Acell would ideally encourage regeneration of mucosa and restore the volume and function of the nasal passages.
• Limitations:
• Like BDCM, Acell’s effectiveness depends on good blood flow. In low-vascular areas, the material might fail to be replaced by functioning tissue, which would cause the support to be lost over time.
• The long-term stability of Acell as a permanent support is questionable in certain areas with poor blood supply. It may not offer lasting volume and structural integrity for ENS patients.
AlloDerm
What it is: AlloDerm is an acellular dermal matrix (ADM) derived from donated human skin tissue. It is processed to remove all cells while retaining the extracellular matrix, which serves as a scaffold for tissue regeneration. AlloDerm is commonly used in reconstructive surgery, including nasal augmentation.
How it works:
AlloDerm provides a structural framework that integrates with the patient’s own tissue over time. It allows the body’s own cells to repopulate the matrix, gradually transforming it into living tissue.
It is flexible and can be shaped to fit the specific needs of nasal reconstruction, making it a useful option for restoring nasal volume and soft tissue support in ENS patients.
Limitations:
While AlloDerm integrates well with the body, it depends on adequate blood supply for successful incorporation. In poorly vascularized areas, integration may be slow or incomplete, potentially leading to resorption.
It is softer than cartilage, meaning it does not provide the same level of rigid structural support. Over time, there may be some loss of volume, particularly in high-pressure areas.
Although it is derived from human tissue, it undergoes extensive processing to remove immunogenic components, but there is still a small risk of immune response or resorption.
Integra
• What it is: Integra is another extracellular matrix (ECM) material, but it’s made up of a silicone layer on top of a collagen-glycosaminoglycan matrix. It’s primarily used in skin grafting and wound healing but also used in soft tissue reconstruction.
• How it works:
• Integra serves as a temporary scaffold for tissue regeneration. The silicone layer protects the underlying tissue while the collagen matrix promotes cell growth and encourages the formation of new tissue.
• As the material is absorbed by the body, it stimulates the growth of new, functional tissue. Integra has been shown to have good integration in areas like the skin or soft tissue, but its application in nasal surgery is still being explored.
• Limitations:
• Like Acell and BDCM, Integra depends on the blood supply in the surrounding tissue to support its regenerative process. In areas with low vascularization, its effectiveness may be limited, leading to a potential failure to regenerate the needed tissue.
• Its temporary nature means that it doesn’t provide permanent support once it breaks down.
Radiesse
• What it is: Radiesse is a dermal filler made from calcium hydroxyapatite (CaHA). It is used in cosmetic procedures to restore volume, particularly in the face, and is sometimes used for nasal volume restoration.
• How it works:
• Radiesse provides immediate volume by directly filling the tissue with calcium-based microspheres. Over time, it stimulates collagen production, which can help maintain volume even after the material is absorbed.
• It is a temporary solution, but the collagen stimulation effect means the results can last for a longer period compared to other fillers (typically 1-2 years).
• Limitations:
• Radiesse is not designed for long-term structural support like cartilage or tissue scaffolds. While it can restore volume temporarily, once it is absorbed, the volume is lost unless new tissue growth is stimulated.
• In areas like the nasal septum, with poor blood flow, Radiesse may not integrate well or regenerate tissue effectively. It doesn’t offer the same kind of permanent, natural tissue replacement as autologous cartilage or biologically regenerative materials like Acell or BDCM.
Polydioxanone (PDO) Mesh or Threads
What it is:
PDO is a biocompatible, absorbable material used in surgery and aesthetic treatments. It comes in the form of mesh or threads that can provide support and volume to the tissue.
Why it is used:
• Stimulates collagen production and can provide some long-lasting volume increase.
• Gradually absorbs while leaving behind newly formed tissue.
• Can create a mild lifting effect in the nose and restore some volume.
Limitations:
• Not a permanent solution.
• Requires good blood supply for optimal results.
Medpor (Porous Polyethylene Implant)
What it is: Medpor is a porous polyethylene structure used in facial reconstruction and has been utilized in rhinoplasty.
Why it is used:
• Provides stability and structural support.
• Integrates with the body's tissue as fibroblasts can grow into its porous structure.
Limitations:
• Can be difficult to remove if needed.
• Risk of infection if not well integrated.
Gore-Tex (Expanded Polytetrafluoroethylene, ePTFE)
What it is: A synthetic implant material used in plastic surgery for volume and structural restoration.
Why it is used:
• Biocompatible and provides long-term support.
• Softer than Medpor, which can be advantageous in some cases.
Limitations:
• Risk of infection and possible extrusion (the material being pushed out of the tissue).
• Less natural integration compared to biological materials.
Hyaluronic Acid Fillers (HA Fillers)
What it is: Hyaluronic acid (HA) fillers, such as Juvederm or Restylane, are injectable dermal fillers that temporarily restore volume by attracting water molecules to the treated area.
Why it’s used:
• Provides a non-surgical, minimally invasive method for restoring lost nasal volume in ENS patients.
• Hydrophilic properties allow for improved mucosal hydration, which may help with dryness-related ENS symptoms.
• Can be adjusted or dissolved with hyaluronidase if necessary, offering reversibility in case of undesired effects.
Limitations:
• Temporary solution, typically lasting 6-12 months before requiring re-injection.
• Not suitable for major structural defects, as it does not provide rigid support like cartilage or Medpor.
• Potential risks include lump formation, uneven distribution, and rare vascular complications if injected improperly.
Silastic (Silicone Implant)
What it is: Silastic is a medical-grade silicone commonly used in nasal implants for augmentation and reconstruction.
Why it’s used:
• Provides immediate and long-lasting volume restoration with a stable structure.
• Can be shaped and customized for specific nasal contouring needs.
• Unlike resorbable materials, it maintains its form permanently, making it an option for patients seeking a stable, long-term solution.
Limitations:
• Silicone implants have a higher risk of infection and extrusion compared to biological materials.
• It does not integrate with natural tissue and remains a foreign body, increasing the risk of displacement or migration over time.
• If complications arise, removal can be challenging and may cause additional structural damage.
Fascia Lata (Autologous Fascia Transplant)
What it is: Fascia lata is a fibrous connective tissue harvested from the thigh. It is often used in reconstructive surgery due to its strong yet flexible properties.
Why it’s used:
• Since it is autologous (from the patient’s own body), it has excellent biocompatibility with minimal risk of rejection or immune reaction.
• It provides a soft tissue augmentation option that can restore some volume in the nasal passages while allowing for some flexibility.
• It is a suitable alternative for patients who do not want cartilage grafts but need a biologically integrative material.
Limitations:
• Requires an additional surgical site (thigh), which may cause post-operative pain and scarring.
• Unlike cartilage, it does not provide rigid structural support and may resorb or shrink over time.
• The success of the graft depends on proper integration with surrounding nasal tissues, requiring sufficient blood supply.
Summary of Implant Materials for ENS
Best Long-Term Options (Most Durable & Biocompatible):
1. Autologous Cartilage (Ear or Rib Cartilage) – Gold standard due to its excellent biocompatibility, long-term stability, and resistance to degradation. Requires an additional surgical site.
2. Donor Cartilage (Cadaveric/Irradiated) – Similar to autologous cartilage but may degrade over time. No need for additional surgery, but risk of resorption exists.
3. Medpor (Porous Polyethylene) – Synthetic material that integrates with tissue, offering structural support. Lower risk of rejection than silicone but not as biocompatible as cartilage.
4. Gore-Tex (ePTFE) – Synthetic, moderately integrates with tissue but carries risk of foreign body reaction.
Temporary or Less Reliable Options:
5. BDCM (Biodegradable Collagen Matrix) & Acell (ECM material) – Promote tissue growth but require good blood supply; degrade over time and may not provide lasting volume.
6. AlloDerm (Acellular Dermal Matrix) – Integrates with tissue but can resorb in areas with poor vascularization. Softer than cartilage.
7. Radiesse (Calcium Hydroxyapatite Filler) – Temporary filler that stimulates collagen but eventually dissolves (1-2 years).
8. PDO Mesh/Threads – Stimulates collagen production but is not a permanent solution.
9. Integra (Collagen-Glycosaminoglycan Matrix with Silicone Layer) – Used for tissue regeneration but requires good blood flow, making long-term stability uncertain.
10. Silastic (Silicone Implant) – Permanent but high risk of rejection and complications, rarely used in nasal surgery today.
Best Choice for ENS Patients?
When it comes to reconstruction for ENS patients, several implant materials are available. Each option has its own advantages and disadvantages depending on factors such as biocompatibility, stability, and risk of complications.
Autologous Cartilage
Pros: The safest and most durable option. Low risk of rejection since it is the patient’s own tissue. Less prone to resorption compared to donor cartilage.
Cons: Requires an additional surgical procedure to harvest cartilage from areas like the ribs or ear.
Donor Cartilage (Cadaveric Cartilage)
Pros: A natural option with good biocompatibility and integration into the body.
Cons: Some risk of resorption over time, which may affect long-term results.
Medpor (Porous Polyethylene)
Pros: Provides strong structural support and does not resorb.
Cons: Higher risk of foreign body reaction, more difficult to remove in case of complications, and increased risk of infection.
Biodegradable Scaffolds (BDCM, Acell, AlloDerm, Integra)
Pros: Can promote tissue regeneration and be useful for soft tissue reconstruction.
Cons: Often unreliable in poorly vascularized areas, making them less effective for ENS patients.
Synthetic Materials (Silicone, Gore-Tex)
Pros: Stable and maintains its shape.
Cons: Higher risk of complications such as infections, extrusion, and tissue irritation.
Summary
Autologous Cartilage is the best and most durable option for ENS patients.
Donor cartilage is a good alternative with good biocompatibility, but it carries a moderate risk of resorption over time.
Biodegradable scaffolds may be beneficial in some cases but are often unreliable in poorly vascularized areas, such as between the mucosa and a cartilaginous or bony wall.
Synthetic Materials have the highest risk of complications and are generally less suitable for ENS patients.
Medpor can be a viable option, but it carries a risk of foreign body reaction, infection, and can be difficult to remove if complications arise
