The History of Rhinoplasty ⑨ — What we have put into the nose: a century of rhinoplasty materials

The body has one old rule.

What is not its own, it pushes out.

This rule does not make many exceptions.

However finely something is made, however well it has been shown to be safe, the body first works out whether it is its own or not.

You could say the long history of materials in rhinoplasty — roughly a hundred years of it — is really the record of a negotiation with that rule.

The first attempt at negotiating failed

It starts with the paraffin from part five. Around 1900, melted paraffin was injected under the skin to fill a sunken bridge.

The idea was attractive. No incision, fill as much as you like, and being liquid it goes anywhere. The early reports were successful.

The trouble showed up later.

The paraffin flowed between the tissues, formed lumps, and caused inflammation. Because the body did not accept it as its own.

There is a lesson in that. The problem is not the moment it goes in but what comes afterwards. Every study of materials since has been built on top of it.

Two ways of handling rejection

The synthetic materials that followed approached the problem in broadly two ways.

One is to make the boundary clear. Silicone works this way.

The body does not accept silicone as its own, but instead builds a thin membrane around it and isolates it.

That is the capsule. It is closer to the body settling on terms: this is not mine, but I will let it stay here.

The advantage of this approach is obvious. The boundary is clear, so removal is comparatively straightforward.

Against that, problems arise if the capsule thickens or contracts, the implant can shift, and over a long time thinning of the nasal skin is reported.

The other way is to blur the boundary. ePTFE — expanded polytetrafluoroethylene, Gore-Tex — works this way, letting tissue grow into its micropores so that the body registers it less as foreign.

This approach produces less capsule formation and less movement. In exchange, since it is entangled with tissue, it is awkward to take out if something like an infection occurs.

To put it plainly: make the boundary clear and it is easier to remove; blur the boundary and it settles better. Neither comes free.

Why it was used more in Asia

There is an anatomical reason for this.

Rhinoplasty in Western patients is mostly reductive surgery. Asian patients, by contrast, often have low, wide nasal bones, weak tip cartilage and thick skin. So augmentation became the centre of the work.

Reduction needs no material; augmentation needs something to fill with. That synthetic implants were used so much in Asia is not only a difference in ideas of beauty but a matter of these structural conditions.

Something to say for balance

Read this far and synthetic implants can look like nothing but trouble. That is not so.

There is something to be clear about here. This is not an argument that synthetic implants are bad. In the literature, removal rates for synthetic implants are reported at the level of a few per cent. Most people go on without a problem.

I hear it from patients every day: don’t these have to come out in ten or twenty years? I’ve heard they all get infected in the end.

They do not.

And the advantages are real: they are easy to work with, the operating time is short, and the result is easier to predict.

What is true is that when a problem does occur in that minority, the situation is difficult.

In those cases the structure has to be rebuilt in autologous tissue strong enough to resist the contracting force, and that is often where rib cartilage becomes necessary.

The relevant literature makes a point to this effect: the only way to avoid contracture caused by a synthetic implant completely is not to use one.

I do not take that sentence as an absolute standard. It does not mean every patient must have autologous tissue only.

But I do agree that in choosing a material you have to reckon with ten and twenty years from now at the same time.

Where a hundred years has arrived

Stand back from the line running from paraffin to the present and one direction becomes visible.

At first we looked for what was easy to put in. Then we looked for what the body pushed out least. And now we have come back, in large part, to a person’s own tissue.

That is progress in technique, and at the same time it is an admission. After testing every kind of substance for a century, the conclusion we arrived at is that the body was right all along.

Medicine is usually thought to advance in the direction of improving on the natural state.

In this field, though, some of what we know was scraped together out of a great many trials and errors running the other way. It took a hundred years to learn what the body will allow and what it will not.