Silicone Bridge Implant Removal and Replacement With Rib Cartilage Graft

Dr. Lamperti narrates an intraoperative video that shows a portion of a revision open rhinoplasty surgery in which he removes a malpositioned silicone bridge implant that was placed in the 1970s. During the same surgery he replaces the implant with a custom carved tissue bank rib cartilage graft and also address the patient's tip asymmetry and alar retraction.

You can see more before and after photos and learn more about the details of this patient's revision rhinoplasty silicone implant removal surgery here.

Video Transcript:

"This is Seattle facial plastic surgeon, Dr. Thomas Lamperti. Today we’re going to go over a surgical case in which I remove a malpositioned silicone bridge implant and replace it with a rib cartilage graft. To start let’s take a look at some photos of our patient. He actually suffered a serious nasal fracture in a motor vehicle accident while active duty in the military in Vietnam in the 1970s. His injury was repaired with a silicone bridge implant which acted as an only graft to rebuild his crushed bridge. Unfortunately, you can see that the implant has shifted out of place to the patient’s left side and downward to create an irregular profile line and a crooked frontal appearance. In addition to this you can see how the patient has quite a bit of tip asymmetry that we’ll also correct during today’s revision rhinoplasty. Here I’m beginning the initial carving of the tissue bank rib cartilage graft. The patient is in his early 80s so we can’t use his own rib as it would be too calcified. I’’m starting by trimming off the outer portions of the cartilage. We’ll then place all the cartilage in a saline bath. This allows us to give the cartilage time to bend and warp. The outer rind will warp the most whereas the central core tends to be the most stable.  If I need curved cartilage (such as for a batten graft) I can use this warping process to my advantage. We’ll now jump back to the nose itself where you can see that I’ve already started the open rhinoplasty dissection. Here I’m gradually lifting the tip skin to reveal the bottom aspect of the silicone implant. Once I can see the implant itself then dissection over the implant to fully free it from the surrounding nasal skin is done. Once I’ve freed up the implant I can then remove it. Since the silicone implant is smooth you can see that it slides out relatively easily. This is in contrast with implants that have a more textured surface which allows for tissue in growth. We’ll now fashion a larger pocket that will allow us to position our newly carved cartilage graft into proper position along the bridge. Since the silicone implant was positioned too low on the nose I’ll obviously need to extend the new pocket up toward the top of the nose at the radix. We’ll now go back to the rib cartilage graft and continue the sculpting process. Besides trimming the cartilage with the scalpel blade I also like to use a scrapping technique at times to further refine and smooth the cartilage in a less aggressive manner. I periodically check the graft for areas of asymmetry and make additional cartilage cuts to make the graft as symmetric as possible.

Next I temporarily insert the graft in the nasal pocket to assess for graft size and shape. The graft is a little long so I’ll trim off a bit of one end to shorten it. At the same time I’ll bevel this edge of the graft to better blend it with the tip. I then replace the graft in the nose to check the new length. I then carefully palpate the graft and check to make sure that the bridge is adequately augmented. I then perform some further refinements to the graft. Once I’m happy with the graft size and shape I’ll suture it into place with several resorbable sutures that will last several months. After this time the graft will have healed into place at which time there is no concern for graft shifting. Before closing the rhinoplasty incisions I do one last check of the graft position and contour.

Now let’s take a look at a few before and after photos showing the patient’s approximately 4 month after results. On frontal view you can see the improved symmetry and lack of an amorphous appearance on the left where the implant was removed. You can also see that I also corrected the patient’s right alar retraction as well. On the right profile view you can now see a much more natural, smooth profile line. Importantly, we’ve created a nice masculine appearance that doesn’t look overdone. This angle also affords a great view of the correction of the right alar retraction which was done using an alar rim graft. The left profile view show a similar improvement to the bridge. You can also see that there was originally some alar rim notching that is now improved as well. Lastly, we’ll look at the base view which shows the significant tip asymmetry that is now much better since the revision rhinoplasty. You can check out the link in the video description to see more before and after photos and to read more about this patients case."